<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002798
Report Date: 07/09/2021
Date Signed: 07/09/2021 10:16:49 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
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: 42DATE:
07/09/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
08:00 PM
MET WITH:Susie Jumawan; AdministratorTIME COMPLETED:
10:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 7/9/21 at 8 PM, Licensing Program Analyst (LPA) Cheng and Singh conducted an unannounced Case Management Health and Safety visit as directed by the department. LPAs met with staff Maria Medrano and explained the reason for the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask and gloves.

LPA toured the facility inside and out including but not limited to facility dining areas, outside front areas, kitchen area, hallway area, and client rooms.

On 7/9/21 at 8:05 PM, LPAs were let into the facility and escorted to the facility office without being screened. When asked if staff members were being screened, LPA's were informed that they were only being screened for temperatures and it was logged into their screening binder. Per Maria and Administrator Susie, symptoms screening were not documented and the last documented symptom screening was dated 5/2021.

During a phone conversation on 7/9/21 with Regional Manager Berryman, Licensing Program Manager Laura Munoz, and Licensing Program Analyst Mai Thao, the licensee stated that the facility is conducting COVID-19 screening protocols with staff and visitors. LPA's Cheng and Singh learned the licensee provided false information as teh facility is not following COVID-19 screening protocols as documented in the facility mitigation plan.

Continuation on LIC 809C.
SUPERVISOR'S NAME: Kevin MknellyTELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: COMFORT HAVEN FOR THE ELDERLY
FACILITY NUMBER: 585002798
VISIT DATE: 07/09/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
On 7/9/2021 at 9PM, LPAs interviewed C1 and observed two cockroaches crawling on the bedroom floor.

Administrator Juwaman stated that the facility has an ongoing pest issue and is receiving monthly pest services.

Facility has five thermostats that measured between 80 - 85 degrees Fahrenheit. LPA's were informed that the A/C unit will be inspected tomorrow morning for it's functioning capability. Facility currently has fans in all hallways and fans in some of the resident rooms. LPA Cheng instructed for facility to obtain three wall liquid thermometer as the Licensee states that the current thermometers may not be providing accurate readings.

Deficiencies are cited on LIC 809D.

Exit interview conducted and a copy of report along with appeals rights were given.
SUPERVISOR'S NAME: Kevin MknellyTELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: COMFORT HAVEN FOR THE ELDERLY
FACILITY NUMBER: 585002798
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/10/2021
Section Cited

1
2
3
4
5
6
7
87468.1 Personal Rights (a)(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
8
9
10
11
12
13
14
Based on observation and records review, Licensee did not follow facility COVID-19 screening protocols which poses an immediate health and safety risk to all clients in care.
8
9
10
11
12
13
14
License will submit two weeks worth of daily COVID-19 symptom screening to LPA via e-mail by 7/23/21.
Type A
07/10/2021
Section Cited

1
2
3
4
5
6
7
87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met as evidenced by:
8
9
10
11
12
13
14
Based on statements, Licensee made false statements to RM, LPM, and RM during a conference call which poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kevin MknellyTELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3