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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002798
Report Date: 12/14/2022
Date Signed: 12/14/2022 01:10:54 PM


Document Has Been Signed on 12/14/2022 01:10 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
CCLD Regional Office, 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: 38DATE:
12/14/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Susie Jumawan, Brian Jumawan, and Administrator/Manager Maria MedranoTIME COMPLETED:
11:00 AM
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
On 12/14/22, around 10am, an office meeting was conducted via Microsoft Teams Platform. The purpose of this office meeting was to discuss the stipulation plan and TSP role for the facility. Present in the meeting is Regional Manager Alycia Berryman, Licensing Program Manager Laura Munoz and Troy Ordonez, Licensing Program Analyst Talwinder Bains, TSP Manager Lauren Crocker, TSP Team members Richard Gasparini and Danielle Walker-Flores, Licensees Susie Jumawan and Brian Jumawan, and Administrator/Manager Maria Medrano. The purpose of the meeting was explained to the licensees.

Topics discussed during the meeting were:
· Licensee/Administrator accountability for current issues with facility
· Facility’s stipulation plan and progress
· TSP team’s role in stipulation program

The following Forms are due by 01/14/2023 and are to be submitted to TSP/RO
Update facility’s plan of operation and identify the population the facility will serve. It should be noted that per Title 22 regulations, resident’s with a diagnosis of dementia and resident’s with a primary diagnosis of a mental disorder unrelated to dementia are not compatible together in a secured facility setting. The licensees shall submit the plan to TSP for departmental review.

The following Forms are due by 12/15/2022 and are to be submitted to TSP/RO
60 Day Eviction (02/14/2023) notice to all residents with primary diagnosis of dementia, should the facility determine that will no longer provide Dementia care services to residents which will be identified in their updated plan of operation.


Copy of this report will be e-mailed to the Licensee for Signature and a signed copy will be returned same day to LPA.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022
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