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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002798
Report Date: 06/13/2024
Date Signed: 06/13/2024 01:12:11 PM


Document Has Been Signed on 06/13/2024 01:12 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: 38DATE:
06/13/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Maria Medrano Administrator/ManagerTIME COMPLETED:
01:15 PM
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On 6-13-24 Licensing Program Analyst LPA Sarah Benson, arrived at the facility unannounced to conducted a quarterly on-site visit regarding the Stipulation and Waiver order, effective three years from 07-26-2022 to 07-26-2025. LPA met with Administrator/Manager Maria Medrano and Brian Jumawan. During today's visit LPA reviewed the Compliance Binder, and observed a copy of the Stipulation is posted and in the binder.

Today LPA toured the facility with Administrator upon arrival.

The following topics were observed and discussed:
-resident supervision
-food service
-roles of the management
-resident conditions
-documentation, incident reports
-staffing and training
-pest control services

LPA reviewed records. LPA Benson has received an email with all staff training, incident report records monthly and pest control records quarterly.

LPA performed the exit interview and gave a copy of the report to Administrator.
No deficiencies cited.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah BensonTELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024
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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