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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508482
Report Date: 02/18/2025
Date Signed: 02/18/2025 02:34:26 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/18/2025 02:34 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: 2DATE:
02/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Ane HaupeakuiTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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LPA Audrey Jeung toured facility and grounds, including detached storage building. There are 3 shared client bedrooms--only 2 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 116 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, as well as staff training records.
Ane Haupeakui and Tomasi Haupeakui oversee facility operations; Tomasi's RCFE administrator certificate expires 2/25.

As per legislation, effective 1/1/2015, the following information is posted: 1) text of Health and Safety Code 1569.269 AND CCR Title 22 Section 87468 (Personal Rights form LIC613C), per AB2171; 2) CCLD Hotline information, per SB895.

The following licensing forms are requested to be completed and submitted to CCLD BY 2/25/25:
- Designation of Administrative Responsibility (LIC308)
- Personnel Report (LIC500)
- Emergency Disaster Plan (revised 9 page LIC610-E signed and dated on page 9)
- 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. Also, see Technical Advisory Note.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2025
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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Document Has Been Signed on 02/18/2025 02:34 PM - It Cannot Be Edited


Created By: Audrey Jeung On 02/18/2025 at 12:11 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: 02/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/25/2025
Section Cited
CCR
87457(c)

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PRE-ADMISSION APPRAISAL
Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455.
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Copies of signed and dated appraisals for clients #1 and #2 will be sent to CCLD BY DUE DATE.
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This requirement is not met, as there are no appraisals maintained for both hospice clients. Client #1 admitted 7/2023 & client #2 admitted 9/2024. This was cited in 2024. Licensee failed to ensure appraisals are completed for clients, which poses a potential health, safety or personal rights risk
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Type B
02/25/2025
Section Cited
CCR87411(c)(1)

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PERSONNEL REQUIREMENTS-GENL
Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement is not met, as there is no documentation maintained that all staff have current first aid training. Licensee failed to
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Proof of current first aid training for staff to be sent to CCLD BY DUE DATE.
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maintain evidence that caregivers have required first aid training, which poses a potential health, safety or personal rigjts risk to clients in care.
This was cited in 2024 and subsequently corrected.
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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:April Cowan
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/18/2025 02:34 PM - It Cannot Be Edited


Created By: Audrey Jeung On 02/18/2025 at 01:26 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: 02/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/25/2025
Section Cited
HSC
1569.695(c)

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HEALTH AND SAFETY CODE
A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may
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Proof of correction to be sent to CCLD BY DUE DATE.
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provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.
- tThere is no record of disaster drills
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Type B
02/25/2025
Section Cited
CCR87470(c)(A-E)

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INFECTION CONTROL PLAN
See page 2 for regulation text.
This requirement is not met, as there is no Infection Control Plan maintained.
This poses a potential health, safety or personal rights risk to clients in care.
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Licensee to complete LIC9282 and send a copy to CCLD BY DUE DATE.

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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:April Cowan
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2025


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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: PETANI HAVEN
FACILITY NUMBER: 410508482
VISIT DATE: 02/18/2025
NARRATIVE
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Facility is not in compliance with Section 87470 Infection Control Plan:

An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.
(1) The Infection Control Plan shall include all of the following:
(A) Identification of a staff position to perform the duties of an Infection Control Lead for the facility.
1. Contact information for the designated Infection Control Lead shall be made available to the department upon request.
2. A description shall be included of how the Infection Control Lead shall be trained by a medical professional, local health official, health department, or other research-based medical authority that provides infection control training that will include enforcement of the Infection Control Plan.
(B) A description of how the licensee shall meet the specific infection control practice requirements of subsections (a), (b) and (d).
(C) An Infection Control Training Plan.
1. Initial training requirements for new facility staff shall be addressed in the plan, with training to be provided by the Infection Control Lead before staff works independently with residents.
2. Ongoing training requirements for all facility staff shall be addressed by the plan, with training to be provided by the Infection Control Lead.
3. The description of initial and ongoing training shall address the requirements of subsections (a), (b) and (d).
(D) The licensee shall review the use of infection control procedures in the facility at least annually, if local government public health determines an epidemic outbreak has occurred, or if the review is requested by the local licensing agency.
(E) The licensee shall ensure that staff encourage residents to follow infection control practices as necessary.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 02/18/2025 02:34 PM - It Cannot Be Edited


Created By: Audrey Jeung On 02/18/2025 at 01:45 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: 02/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/19/2025
Section Cited
CCR
87355(e)(1)

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CRIMINAL RECORD CLEARANCE
All individuals subject to a criminal record review pursuant to HSC Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
obtain a CA clearance or a criminal record exemption as required by the Department
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Staff #1 will resubmit fingerprints in order to obtain criminal record clearance.
Licensee must follow up to associate criminal record clearance to facility and submit proof of correction to CCLD BY DUE DATE.
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This requirement is not met as staff #1 is present at facility, but has not yet obtained criminal record clearance. Licensee failed to ensure that all staff have criminal record clearance prior to working with clients. This poses an immediate health, safety or personal rights risk to clients in care.
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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:April Cowan
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2025


LIC809 (FAS) - (06/04)
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