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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002798
Report Date: 12/18/2023
Date Signed: 12/18/2023 03:57:50 PM


Document Has Been Signed on 12/18/2023 03:57 PM - 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:
12/18/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Susie Jumawan AdministratorTIME COMPLETED:
04:15 PM
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On 12-18-23 Licensing Program Analyst LPA Sarah Benson arrived at the facility unannounced to conduct a case management visit. LPA met with Susie Jumawan Administrator and Administrator/Manager- Maria Medrano. Incident/injury report submitted by facility on 12-03-23 concerning resident reporting sexual allegations.
Maria Medrano reported resident asked to use the phone on 12-02-23 and a few minutes later two police officers arrived in response to 911 call. The resident told the police she had been raped when she moved to facility back in September 2023.
Maria stated after questioning and an evaluation by police the resident was taken to Yuba Sutter Mental Health then transported to Hospital for evaluation. The hospital called facility to release the resident back to facility on 12-3-23.
Susie Jumawan stated the resident has been moved to a room closer to staff office for closer monitoring and the comfort of resident. Susie stated the facility moved a roommate in with resident to help her feel safe and have companionship.
LPA interviewed the administrator, 1 staff and 1 client during the visit. LPA requested the following documents during the visit: admission agreement and medical records for one resident.


No deficiencies cited. Needs further investigation. Exit interview conducted and a copy of the report was provided to administrator Susie Jumawan.




SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah BensonTELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2023
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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