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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002798
Report Date: 06/11/2021
Date Signed: 06/11/2021 11:45:34 AM

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: 40DATE:
06/11/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Brian JumawanTIME COMPLETED:
12:00 PM
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LPA Tryon arrived at the facility to conduct a case management visit. LPA had checked ahead of time to screen the facility for the visit; and learned there are no current cases of COVID-19 and no known reecent exposures.to COVID and no one with any symptoms. Resident R1 normally goes into the community daily. Last month he had let the home know he wanted to move. Last week on 6/4/.2021 staff noted that R1 had not come in to get his dinner. He did not return that night, and police were notified that he had not returned. Police stated that they would not come out if he was allowed out on his own. The licensee drove all around the area looking for R1, but did not find him. At 24 hours they did issue a bulletin. The home called police, hospitals, the mission, jail, and did not find him. Resident did not return until today. Today he called the facility and asked if he could come back. The licensee then and picked up R1 and brought him home. He is planning to stay at the facility at this time.

It appear that the facility followed protocol and procedures, notified police, licensing, looked for the resident, etc.

No deficiencies are issued at this time.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 208-7709
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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