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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002798
Report Date: 01/30/2023
Date Signed: 01/30/2023 11:10:52 AM


Document Has Been Signed on 01/30/2023 11:10 AM - 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: 35DATE:
01/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Administrator/Manager- Maria MedranoTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 01/30/2023
to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Administrator/Manager- Maria Medrano and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA wore the following Personal Protective Equipment (PPE) during today's visit: surgical mask. LPA was screened by staff upon facility entry.

LPA and administrator toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to: bedrooms and bathrooms for residents, common areas, dining room, kitchen area, laundry room and outdoor area. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA and administrator completed the infection control domain and facility was found to be in substantial compliance at this time.

No deficiencies are being observed or cited as a result of today's inspection.
Exit interview conducted and copy of report left at the facility.






SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2023
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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