585002798-5-5-2023-25-AS-LMUZ-CRK4EA-20230505190159

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 585002798
Report Date: 05/05/2023
Date Signed: 05/05/2023 09:59:41 AM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/21/2023 and conducted by Evaluator Melissa Parks

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20230221143925

FACILITY NAME:	COMFORT HAVEN FOR THE ELDERLY		FACILITY NUMBER:	585002798
ADMINISTRATOR:	JUMAWAN, SUSIE		FACILITY TYPE:	740
ADDRESS:	125 E TENTH STREET		TELEPHONE:	(530) 777-9698
CITY:	MARYSVILLE	STATE: CA	ZIP CODE:	95901
CAPACITY:	48	CENSUS: 38	DATE:	05/05/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Maria Medrano		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Illegal Eviction

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Melissa Parks arrived at the facility unannounced to deliver complaint findings into the allegation listed above and met with Administrator Maria.

During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows:
Illegal Eviction

The facility provided a number of residents with eviction letters that were approved by the Department. As of this day Friday May 5, 2023, all eviction notices have been retracted. Therefore, the allegation is unfounded meaning that the allegation is false, could not have happened, and/or is without a reasonable basis.
Exit interview was conducted with Maria and a copy of this report was provided to the facility. The signature of the Administrator on these forms acknowledges receipt of these documents.

Unfounded

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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