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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002798
Report Date: 07/11/2021
Date Signed: 07/11/2021 05:59:28 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:
07/11/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Susie Jumawan; AdministratorTIME COMPLETED:
04:00 PM
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On 7/11/21 at 3 PM, Licensing Program Analyst (LPA) Cheng conducted an unannounced Case Management Health and Safety Check as directed by the department. LPA met with Administrator Susie Jumawan 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: surgical mask and gloves.

LPA toured the facility inside and out including but not limited to facility hallways, living room, facility office, resident rooms, and hallway bathrooms.

On 7/11/21 at 3 PM, LPA Cheng observed the following temperatures in their area. Facility left hallway entrance measured at 68.5 degrees Fahrenheit, resident room #25 measured 61 degrees Fahrenheit, right hallway entrance measured 63 degrees Fahrenheit, room #6 measured 66 degrees Fahrenheit, and living room air vent measured 58.5 degrees Fahrenheit. All of facility liquid thermometers measured at 80 degrees Fahrenheit.

LPA observed two new air conditioners at the facility; one installed in each hallway.
Current temperature outside of the facility measures at 103 degrees Fahrenheit.
No deficiency observed.

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

DATE: 07/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2021
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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