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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601040
Report Date: 12/23/2022
Date Signed: 12/23/2022 11:45:22 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/14/2022 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20221214141018
FACILITY NAME:HAVEN@22ND AVENUE ASSISTED LIVINGFACILITY NUMBER:
415601040
ADMINISTRATOR:COMFORT, MARIAFACILITY TYPE:
740
ADDRESS:304 22ND AVETELEPHONE:
(415) 519-1110
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:6CENSUS: 6DATE:
12/23/2022
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Licensee/Administrator, Maria ComfortTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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-Facility staff are not following COVID-19 guidelines
-Facility does not have sufficient staff
-Facility staff are not trained
-Facility dogs bit a visitor
INVESTIGATION FINDINGS:
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On December 23, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver findings for the above allegations. LPA met with Licensee/Administrator, Maria Comfort and explained the purpose of the visit. LPA was screened at entry point.

Regarding the allegation that facility staff are not following COVID-19 guidelines, according to the reporting party, he/she was not screened at the front door nor was his/her temperature taken upon arrival. During the investigation, LPA interviewed Licensee and reviewed the visitor screening log documentation. According to the Licensee, she hired new staff and the staff were aware that visitors needed to be screened upon arrival, however the Licensee acknowledged that the staff did not check the visitor's temperature upon arrival that day due to staff being distracted.

Regarding the allegation that facility does not have sufficient staff, according to the
reporting party, the Licensee admitted she is short-staffed and is constantly working. During the investigation, LPA interviewed the Licensee and reviewed the LIC500 (Personnel Report). According to the Licensee, it was acknowledged, she does not have enough staff and is trying to hire more caergivers. In addition, LPA visited the facility on 12/20/2022 and 12/23/2022, and the Licensee and the Licensee's sister was the only staff present for the six residents, however the Licensee indicated that her sister does not assist residents in care.

CONT. TO 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 14-AS-20221214141018
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: HAVEN@22ND AVENUE ASSISTED LIVING
FACILITY NUMBER: 415601040
VISIT DATE: 12/23/2022
NARRATIVE
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Regarding the allegation that facility staff are not trained, according to the reporting party, the Licensee admitted she short-staffed and the new staff are not trained. In addition, according to the reporting party, the Licensee's sister who is the assigned facility cook is not trained. During the investigation, LPA reviewed training records and interviewed the Licensee. According to the Licensee, it was acknowledged that the new staff present were trained regarding COVID-19 protocols and screening procedures and was given training log documentation. In addition, LPA requested training documentation for the Licensee's sister, however, the Licensee was unable to provide LPA training documentation for her sister who handles the resident's food.

Regarding the allegation that the facility dogs bit a visitor, according to the reporting party, on 12/8/22, he/she visited the facility and a caregiver opened the door with two dogs barking at his feet. In addition, the reporting party indicated that the dogs bit his/her legs. During the investigation, LPA interviewed the Licensee and the Licensee admitted the day of the incident, she had two new staff members present at the facility and they were not aware that they needed to put the dogs in the room prior to opening the front door. The Licensee indicated that the dogs bit the visitor and provided the visitor with the dogs rabies shots. Animal control was called and the dogs were quarantined for 10 days.

Based on the information collected and interviews conducted, it was determined that the preponderance of evidence standard has been met; therefore, the above allegations are determined to be SUBSTANTIATED.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 9099D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with Licensee and a copy is provided with appeals rights.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/14/2022 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20221214141018

FACILITY NAME:HAVEN@22ND AVENUE ASSISTED LIVINGFACILITY NUMBER:
415601040
ADMINISTRATOR:COMFORT, MARIAFACILITY TYPE:
740
ADDRESS:304 22ND AVETELEPHONE:
(415) 519-1110
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:6CENSUS: 6DATE:
12/23/2022
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Licensee/Administrator, Maria ComfortTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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-Facility staff are not providing a safe environment for the residents in care
INVESTIGATION FINDINGS:
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On December 23, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver findings for the above allegation. LPA met with Licensee/Administrator, Maria Comfort and explained the purpose of the visit. LPA was screened at entry point.

Regarding the allegation that facility staff are not providing a safe environment for residents in care, according to the reporting party, the facility is not a safe environment for residents in care as there are four dogs at the facility and on several occasions the dogs were observed in the yard, running down the hall and in the dining area. During the investigation, LPA interviewed the Licensee and the resident's responsible parties.

According to the Licensee, she has never seen the dogs bite or harm any of the residents in care. In addition, based on interviews conducted, the responsible parties indicated that the facility is safe and the Licensee provides adequate care to the residents at the facility. Furthermore, the responsible parties interviewed indicated that they have not had any issues with the dogs at the facility because the Licensee puts them outside or in a room prior to letting visitors into the facility.

Therefore, based on the information collected, and interviews conducted, the allegatiion that the facility staff are not providing a safe environement for residents in care is UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred.

Report is reviewed with Licensee and a copy is provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 14-AS-20221214141018
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: HAVEN@22ND AVENUE ASSISTED LIVING
FACILITY NUMBER: 415601040
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/30/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations...

Violation of this regulation is evidenced by:
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Licensee to conduct in-service training regarding COVID-19 protocols and screening procedures.
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Based on record revieed and interviews, the facility failed to check visitor's temperature on 12/8/22. In addition, according to the Licensee, it was acknowledged that the new staff were unaware to check visitor's temperature upon arrival.
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Type B
12/30/2022
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...

Violation of this regulation is evidenced by:
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Licensee to submit a plan to how facility can meet CCR 87411(a) by due date.
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Based on record reviewed and interviews conducted, it was noted that the Licensee is the only one providing care to six residents. In addition, the Licensee acknoweldged she is short-staffed and is trying to hire more caregivers.
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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.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 14-AS-20221214141018
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: HAVEN@22ND AVENUE ASSISTED LIVING
FACILITY NUMBER: 415601040
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/30/2022
Section Cited
CCR
87411(d)(1)
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87411 Personnel Requirements: (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance...(1) Principles of good nutrition, good food preparation and storage, and menu planning.

Violation of this regulation is evidenced by:
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Licensee to conduct in-service training for food handling and preparation and submit LPA a copy by due date.
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Based on records reviewed, the Licensee failed to provide training to the facility cook in relation to food preparation and proper food handling.
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Type B
12/30/2022
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times...for the safety and well-being of residents, employees and visitors.

Violation of this regulation is evidenced by:
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Licensee will conduct in-service training with staff regarding putting dogs away prior to opening the door to visitors and will submit a copy of the training log to CCLD by 12/30/22.
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Based on the interview conducted, the Licensee admitted that on 12/8/22 the facility dogs bit a visitor because the facility staff failed to put the dogs away in a room prior to allowing visitors in.
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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.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5