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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601040
Report Date: 12/21/2023
Date Signed: 12/21/2023 10:29:08 AM

Unfounded


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
12/07/2023 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20231207101130
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: 5DATE:
12/21/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Caregiver, Merlinda MalalacTIME COMPLETED:
10:38 AM
ALLEGATION(S):
1
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9
Licensee is not ensuring that the facility has sufficient resources to meet operating costs for the care of residents.
INVESTIGATION FINDINGS:
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2
3
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5
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9
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12
13
On December 21, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit. LPA met with Caregiver, Merlinda Malalac and explained the purpose of the visit. Caregiver called Administrator, Maria Comfort and LPA also notified Administrator of the visit.

Regarding the allegation, Licensee is not ensuring that the facility has sufficient resources to meet operating costs for the care of residents, there is no further information forthcoming, however during the initial reporting, the reporting party indicated that the facility is experiencing a financial crisis.

During the investigation, LPA interviewed the administrator, toured the facility, and interviewed staff. The administrator denied the allegation and indicated that the facility is doing very well and all the bills are getting paid on time. LPA toured the facility and observed 2-day perishable and 7-day non-perishables present, in addition to an another refrigerator in the garage that was observed to have additional non-perishables and perishables. Hot water temperature measured between 105-115 degrees F throughout the facility.

Based on 2/2 staff interviewed, they also denied this allegation and indicated that the facility has sufficient resources to meet resident's needs. Based on the above information, the Department has found that this allegation to be UNFOUNDED, meaning that this allegation was false, could not have happened and/or is without a reasonable basis.

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

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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