<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002798
Report Date: 10/27/2022
Date Signed: 10/27/2022 02:52:29 PM


Document Has Been Signed on 10/27/2022 02:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:COMFORT HAVEN FOR THE ELDERLYFACILITY NUMBER:
585002798
ADMINISTRATOR:JUMAWAN, SUSIEFACILITY TYPE:
740
ADDRESS:125 E TENTH STREETTELEPHONE:
(530) 777-9698
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY:48CENSUS: 39DATE:
10/27/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Susie Jumawan, Brian Jumawan, and Administrator/Manager Maria MedranoTIME COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
LPA Hiratsuka, conducted this quarterly probation visit. LPA met with Administrator/Manager(AM) Maria Medrano, Licensees/Administrator (L1)Susie and(L2) Brian Jumawan. LPA wore a surgical mask during this visit and observed all staff wearing masks during the visit.

Today LPA toured the facility with AM upon arrival.

The following topics were discussed:
-resident supervision
-food service
-roles of the management
-resident conditions
-documentation
-staffing

LPA received a copy of most of the staff training for the month of October. There are four staff that still need training.

No deficiencies cited.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1