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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002798
Report Date: 03/07/2023
Date Signed: 03/07/2023 11:28:18 AM


Document Has Been Signed on 03/07/2023 11:28 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



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:
03/07/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Maria MedranoTIME COMPLETED:
12:00 PM
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Licensing Program Manager (LPM) Laura Munoz, LPM Lauren Crocker, Regional Manager (RM) Alycia Berryman and Licensing Program Analyst (LPA) Lavinia Muscan arrived to do a health and safety check. LPMs LPA and RM completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. The following Personal Protective Equipment (PPE) was worn: Surgical Mask.

Upon arriving at the facility LPA, LPMS and RM toured the facility and met with Administrator to discuss facility's program plan and staffing regarding meeting residents needs.

During todays visit the licensees were not present due to being out of town and a meeting will be requested with the licensees to discuss the current operation of the facility.


No citations.


Exit interview conducted.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2023
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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