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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 585002798
Report Date: 12/16/2024
Date Signed: 12/16/2024 10:45:27 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/13/2024 and conducted by Evaluator Donna Gurriere
COMPLAINT CONTROL NUMBER: 59-AS-20240913091532
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:
12/16/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:MARIA MEDRANOTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff did not prevent resident from their personal rights being violated by another resident in care.
INVESTIGATION FINDINGS:
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On 12/16/24 Donna Gurriere, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 09/13/24. LPA Gurriere met with Maria Medrano, Administrator and explained the purpose of the visit.

Staff did not prevent resident from their personal rights being violated by another resident in care.

During the interview process the administrator, the conservator to the resident, and the resident (Resident 1), were interviewed. Documents were obtained to include the Personnel Report, Admission Agreement, Appraisal Needs and Services, Police Report and several Incident Reports.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 59-AS-20240913091532
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 12/16/2024
NARRATIVE
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On 08/28/24, the police arrived at the facility to investigate a sexual assault that reportedly happened on 08/12/24. The resident (Resident 1) stated that a person came into her bedroom and approached her during the nighttime by lying on top and groping her. It was stated that the resident raised her voice and told the person to "Stop!" “Get out, someone is going to see you!” The person then left the bedroom. It is unknown if it was a staff person or another resident. The roommate was sleeping this date and was not interviewed; however was interviewed by the police and stated that she heard nothing. The resident stated that the incident did happen; however there are no witnesses to confirm the allegation.

Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above findings are Unsubstantiated.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2