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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
585002798
Report Date:
04/22/2024
Date Signed:
04/22/2024 05:00:02 PM
Document Has Been Signed on
04/22/2024 05:00 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:
36
DATE:
04/22/2024
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME BEGAN:
04:15 PM
MET WITH:
Maria Medrano Administrator
TIME COMPLETED:
04:45 PM
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On 4-22-24 at 4:15PM Licensing Program Analyst LPA Sarah Benson arrived at the facility to follow up on incident report received 4-16-24 concerning coaxes wound for a resident in care. LPA Benson met with Maria Medrano Administrator and reviewed medical records.
The resident in question did not have a coaxes wound. The resident in question
has a rash on right buttock treated with desitin cream four to six times a day. The rash is healing.
SUPERVISOR'S NAME:
Lauren Crocker
TELEPHONE:
(916) 261-4966
LICENSING EVALUATOR NAME:
Sarah Benson
TELEPHONE:
530-895-5033
LICENSING EVALUATOR SIGNATURE:
DATE:
04/22/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/22/2024
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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