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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002798
Report Date: 07/09/2024
Date Signed: 07/09/2024 05:30:23 PM


Document Has Been Signed on 07/09/2024 05:30 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: 37DATE:
07/09/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
04:50 PM
MET WITH:Maria Medrano Administrator/ManagerTIME COMPLETED:
05:30 PM
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On 7-9-24 at 4:30PM Licensing Program Analyst LPA Sarah Benson arrived at the facility unannounced to investigate an incident report the facility reported on 7-8-24 about facility AC not working.

LPA Benson and Maria Medrano Administrator/Manager toured the facility together. LPA Benson tested the temperature in three locations, a room in the east wing was 73.3 degrees, west wing 78.3 degrees and TV area 73.1 degrees.

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: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024
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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