585002798-2-2-2024-59-AS-SBEN-D23V5Y-20240202150842

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 585002798
Report Date: 02/02/2024
Date Signed: 02/02/2024 03:08:50 PM

Document Has Been Signed on 02/02/2024 03:08 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 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:	02/02/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Maria Medrano Administrator		TIME COMPLETED:	03:30 PM

NARRATIVE

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02/2/2024 10:30 AM Licensing Program Analyst (LPA) Sarah Benson arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with Maria Medrano the administrator (cert #6026602740 exp:8-8-25) and explained the purpose of the visit. Administrator certificate is current.

LPA Benson and administrator toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to four (4) resident rooms, common areas, two (2) bathrooms, kitchen, storage areas and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. Staff and resident files were reviewed. Medications were also reviewed. Medication is locked in a locked closet.

The common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. The bathrooms were clean and in good repair. The kitchen was clean and in good repair. Cooking/dining equipment and utensils were present. Food appears to be stored and prepared properly.

The facility was observed to be at a comfortable temperature. First aid kit fully stocked and ready for emergency use. Fire extinguisher fully charged. Smoke detectors are all operational. Hot water temperature measured within required Title 22 regulations of 105 degrees F and 120 degrees F. All employees requiring background checks are cleared. There is a schedule of activities Planned for the clients. All required postings are displayed within the facility.

No pools/bodies of water are on the premises. No firearms are on premises. The facility has been conducting drills every 6 months.

The following deficiencies were observed (See LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, a copy of the report, and appeal rights provided to administrator Maria Medrano.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah Benson	TELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024

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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Document Has Been Signed on 02/02/2024 03:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 ELDERLY	FACILITY NUMBER: 585002798
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(6)

Incidental Medical and Dental Care Services

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observarion, interview and record reveiw, the licensee did not comply with the section cited above in one out of three medication reviews, discontinued medication was noted as given to a resident, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/23/2024
	Plan of Correction
1 2 3 4	Medication training for all staff with medication delivery. Have pharmacy present a training. Notify LPA by email when complete.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah Benson	TELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/02/2024 03:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 ELDERLY	FACILITY NUMBER: 585002798
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.69(g)

Other Provisions

(g) Residential care facilities for the elderly licensed to provide care for 16 or more persons shall maintain documentation that demonstrates that a consultant pharmacist or nurse has reviewed the facility’s medication management program and procedures at least twice a year. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interveiw and record reveiw, the licensee did not comply with the section cited above in one out of two visits by a nurse or consultant pharmacist, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/23/2024
	Plan of Correction
1 2 3 4	Have a pharmacist or nurse reveiw the facilities medication management program and procedures at least twice a year. Create a document to keep record of the reviews done twice a year. Notify LPA by email when first review is complete. Notify LPA by email when document is created.

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, record review, the licensee did not comply with the section cited above in the facility only performed two drills last year and have not record, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/12/2024
	Plan of Correction
1 2 3 4	Create a document to record fire/emergency drills performed quarterly. Send an email to LPA when complete

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah Benson	TELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024

LIC809 (FAS) - (06/04)

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