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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002798
Report Date: 03/06/2024
Date Signed: 03/06/2024 08:03:28 AM


Document Has Been Signed on 03/06/2024 08:03 AM - 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:
03/06/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
07:00 AM
MET WITH:Maria Medrano AdministratorTIME COMPLETED:
08:18 AM
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On 3-06-24 Licensing Program Analyst LPA Sarah Benson, arrived at the facility unannounced to conducted a quarterly probation visit. LPA met with Administrator/Manager Maria Medrano.

Today LPA toured the facility with Administrator upon arrival.

The following topics were discussed:
-resident supervision
-food service
-roles of the management
-resident conditions
-documentation
-staffing

LPA received copies of the staff trainings. LPA Sbenson requested in the future, a form with all staff training's recorded on a single sheet to be emailed to licensing monthly.

LPA performed the exit interview and gave a copy of the report to Administrator Maria Medrano.
No deficiencies cited.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah BensonTELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024
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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