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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601040
Report Date: 02/08/2024
Date Signed: 02/08/2024 01:01:16 PM


Document Has Been Signed on 02/08/2024 01:01 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
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:
02/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator, Maria ComfortTIME COMPLETED:
01:15 PM
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On February 8, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA met with Administrator, Maria Comfort and explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, common areas & kitchen. The indoor and outdoor passageways were free of obstruction. No accessible bodies of water of fire safety hazards observed. Extra linen was observed. LPA toured all six single resident rooms with half bathrooms in each room and observed them to clean with all required furniture. Two staff rooms were observed. LPA observed one full bathroom and one main shower room to be clean and free from odor.

A comfortable temperature of 69 degrees F is maintained and lighting is sufficient for comfort. Hot water was also tested between 105-115 degrees F throughout the facility. Sharps, toxins and medication were locked and inaccessible to residents. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current as of February 2023. LPA observed 2 days for perishables and 7 days non-perishables. Emergency drills are logged and done every three months.

LPA to return back to the facility in the future to review staff and resident records.

No citations were issued during this visit. LPA reviewed report with Administrator and a copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024
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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