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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002798
Report Date: 08/22/2023
Date Signed: 08/22/2023 11:00:18 AM


Document Has Been Signed on 08/22/2023 11:00 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 36DATE:
08/22/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator Maria MedranoTIME COMPLETED:
11:15 AM
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On 08/22/23, Licensing Program Analyst (LPA) Talwinder Bains and Licensing Program Analyst (LPA) Sarah Benson arrived to conduct a case management and perform a health and safety check on residents in care. LPAs met with administrator Maria Medrano and explained the purpose of todays' visit. LPAs were screened by staff upon arrival including temperature.

LPAs toured the facility with Administrator to check the health and safety of residents in care. Areas toured included but not limited to residents rooms, bathrooms, common areas and outside area. LPAs toured kitchen area and observed that facility has adequate food supply of 2 days perishable and 7 days non perishable per regulation. LPAs observed some residents were in common area and some are in their rooms resting after breakfast. LPAs observed that facility was clean and odor free. LPAs observed that staff were attentive to residents care needs during tour. LPAs observed residents appear to be happy and in good care during today's visit. From the tour, there was no immediate health and safety risks observed for the residents in care.

The following topics were discussed:


-resident supervision
-food service
-roles of the management
-resident conditions
-documentation
-staffing
-paper supply

As a result of today’s visit, no deficiencies were observed or cited.
The report was reviewed, and a copy was left at the facility.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah BensonTELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023
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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