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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601040
Report Date: 12/23/2022
Date Signed: 12/23/2022 11:46:47 AM

Document Has Been Signed on 12/23/2022 11:46 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 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
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Licensee/Administrator, Maria ComfortTIME COMPLETED:
12:00 PM
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On December 23, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit in relation to a complaint (complaint control # 14-AS-20221214141018). LPA met with Licensee/Administrator, Maria Comfort and explained the purpose of the visit.

During a complaint investigation; complaint control #14-AS-20221214141018, the Licensee indicated she is assisting a resident transfer with a hoyer lift by herself.

During the visit, LPA requested records of hoyer lift training. According to the Licensee, she has done any training with the nurse regarding hoyer lifts , however was unable to provide records.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. 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
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 12/23/2022 11:46 AM - It Cannot Be Edited


Created By: Komal Charitra On 12/23/2022 at 11:23 AM
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: 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
87412(c)

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87412 Personnel Records:
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.
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Licensee will take trainings regarding hoyer lifts and conduct an in-service training with caregivers on how to properly operate a hoyer lift by due date.
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Violation of this regulation is evidenced by:

Licensee failed to provide hoyer lift training.
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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: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


LIC809 (FAS) - (06/04)
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