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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508482
Report Date: 01/20/2026
Date Signed: 01/20/2026 05:49:47 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/20/2026 05:49 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:PETANI HAVENFACILITY NUMBER:
410508482
ADMINISTRATOR/
DIRECTOR:		HAUPEAKUI, ANEFACILITY TYPE:
740
ADDRESS:1840 EVERGREEN STREETTELEPHONE:
(650) 343-8153
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY: 6CENSUS: 4DATE:
01/20/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:45 PM
MET WITH:Ane Haupeakui and Aja HunkinTIME VISIT/
INSPECTION COMPLETED:
06:00 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
LPA Audrey Jeung toured facility and grounds, including detached storage building. There are client bedrooms--two are occupied as private rooms--a staff room, 2 full bathrooms, living/dining room, TV room, and kitchen. Washer and dryer are located in 1-car garage. There are no accessible bodies of water or fire safety hazards observed. Carbon monoxide detector is tested and operable. Hot water temperature is tested at 113 degrees in rear client bathroom. Medications and sharps are stored appropriately and inaccessible to clients, a comfortable room temperature is maintained, and lighting is sufficient for safety. First-aid kit is maintained and complete. Client files are reviewed, including Centrally Stored Medications Records. A Disaster and Mass Casualty Plan is posted. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, however, staff records are not available for review. Ane Haupeakui and Esther Hunkin oversee facility operations; Esther Hunkin's RCFE administrator certificate expires 8/27.

The following licensing forms are requested to be completed and submitted to CCLD BY 2/3/26:
- Designation of Administrative Responsibility (LIC308)
- Personnel Report (LIC500)
- page 9 of revised Emergency Disaster Plan (signed and dated)
- Facility Sketch (LIC999), including dimensions
- Proof of current liability insurance

Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on following pages.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Audrey Jeung
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2026
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 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 6
Document Has Been Signed on 01/20/2026 05:49 PM - It Cannot Be Edited


Created By: Audrey Jeung On 01/20/2026 at 04:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PETANI HAVEN
FACILITY NUMBER: 410508482

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/20/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/20/2026
Section Cited
CCR
87608(a)(5)(B)

1
2
3
4
5
6
7
POSTURAL SUPPORTS
Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
This requirement is not met, as hospice
1
2
3
4
5
6
7
Copy of hospice care plan for client #2--including full bed rails order--was provided during visit.
Deficiency corrected and cleared.
8
9
10
11
12
13
14
client #2 has full bed rails, but this is not included in hospice care plan. Licensee failed to ensure that full bed rails are included in hospice care plan, which poses a potential health, safety or personal rights risk to clients in care.
8
9
10
11
12
13
14
Type A
01/20/2026
Section Cited
CCR87465(h)(6)

1
2
3
4
5
6
7
INCIDENTAL MEDICAL CARE 87465
A record of centrally stored prescription medications for each resident shall be maintained and include names of the resident for whom prescribed, prescribing physician and pharmacist, drug name, strength and quantity, dates filled, started
1
2
3
4
5
6
7
Clients' medications were logged on CSMR in LPA's presence.
Deficiency corrected and cleared
8
9
10
11
12
13
14
& expiration, prescription number and instructions. This requirement is not met, as medications for 3 residents are not recorded on Centrally Stored Medications Records. Licensee failed to ensure that medications for clients are logged on CSMR, which poses a potential health or safety risk.
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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2026


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 01/20/2026 05:49 PM - It Cannot Be Edited


Created By: Audrey Jeung On 01/20/2026 at 04:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PETANI HAVEN
FACILITY NUMBER: 410508482

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/20/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/03/2026
Section Cited
CCR
87305(a)

1
2
3
4
5
6
7
ALTERATIONS TO BUILDINGS/GROUNDS
Prior to construction or alterations, all facilities shall obtain a building permit.
This requirement is not met, as rear family room has been extended almost 8 feet, but there is no approved building permit. Licensee failed to maintain approved
1
2
3
4
5
6
7
Plan/proof of correction to be sent to CCLD BY DUE DATE
8
9
10
11
12
13
14
building permit, which poses a potential health, safety or personal rights risk to clients in care.
8
9
10
11
12
13
14
Type B
01/27/2026
Section Cited
CCR87458(a)

1
2
3
4
5
6
7
MEDICAL ASSESSMENT
Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.
1
2
3
4
5
6
7
Copies of MD reports for clients #3 and #4 will be sent to CCLD BY DUE DATE
8
9
10
11
12
13
14
This requirement is not met, as there are no MD reports for clients #3 and #4. Licensee failed to ensrue that MD reports are maintained prior to admission and maintained, which poses a potential health, safety or personal rights risk to clients 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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2026


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 01/20/2026 05:49 PM - It Cannot Be Edited


Created By: Audrey Jeung On 01/20/2026 at 04:50 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PETANI HAVEN
FACILITY NUMBER: 410508482

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/20/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/21/2026
Section Cited
CCR
87412(g)

1
2
3
4
5
6
7
PERSONNEL RECORDS
All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. This requirement is not met, as there are no staff records available for review. Licensee failed to ensure that staff records are maintained
1
2
3
4
5
6
7
Proof of correction to be sent to CCLD BY DUE DATE
8
9
10
11
12
13
14
at facility, which poses an immediate health, safety, or personal rights risk to clients in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2026


LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 01/20/2026 05:49 PM - It Cannot Be Edited


Created By: Audrey Jeung On 01/20/2026 at 05:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PETANI HAVEN
FACILITY NUMBER: 410508482

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/20/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/27/2026
Section Cited
CCR
87457(c)

1
2
3
4
5
6
7
PREADMISSION APPRAISAL
Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs. This requirement is not met, as there are no appraisals on file for all residents. Licensee failed to ensure
1
2
3
4
5
6
7
Copies of appraisals for all 4 residents will be sent to CCLD BY DUE DATE.
8
9
10
11
12
13
14
that appraisals are maintained for all clients, with poses a potential health, safety or personal rights risk to clients in care.
No preadmission appraisals for clients #3 and #4 and no appraisals for clients #1 and #2
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6