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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601040
Report Date: 11/17/2022
Date Signed: 11/17/2022 10:48:19 AM

Document Has Been Signed on 11/17/2022 10:48 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:
11/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee/ Administrator, Maria ComfortTIME COMPLETED:
10:57 AM
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On November 17, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. Upon arrival, LPA observed the COVID-19 signage posted at the front entrance. LPA met with Licensee/Administrator, Maria Comfort and explained the purpose of the visit. LPA was not screened at entry point and Licensee was unable to provide LPA screening log documentation for visitors and staff, however was able to provide COVID screening log documentation for residents. According to the Licensee, staff and visitor's temperatures are taken but is not being documented.

LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a single story home with 2 staff rooms, 6 resident rooms with half-baths in each room, and 2 full bathrooms. LPA observed the two staff room to be clean. One of the full bathrooms were observed with liquid soap, paper-towels and a trash can with a fitted lid. LPA advised Licensee to remove bath-towels, hand-towels and bar soaps. LPA observed extra linen present. LPA toured the facility with the Licensee and observed living room and dining room to be clean and free from any tripping hazards. A comfortable temperature of 66 degrees F is maintained and lighting is sufficient for comfort. During the visit, LPA observed 2 residents having breakfast and 1 resident watching television.

LPA toured 6 resident rooms and all were observed to be private rooms with half-baths in each room. All rooms and bathrooms were clean and odor-free. LPA observed the second bathroom to be a resident shower room. LPA toured the kitchen and observed 2 day perishable and 7 day non-perishable. Sharps were observed to be locked and inaccessible to residents. LPA advised Licensee to remove hand-towels from the kitchen. LPA toured the garage and observed extra food supply present. LPA observed a storage room above the garage. 30-day PPE supply was present.

LPA observed the laundry room to have a washer and dryer in good repair. Medications were observed to be locked in a cabinet in the laundry room, however chemicals and toxins were observed to be unlocked. According to the Licensee, staff were using the chemicals to wash clothes. Licensee locked the chemicals and toxins in LPA's presence. LPA observed office room with two dogs.

CONT. TO 809C
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
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 11/17/2022 10:48 AM - It Cannot Be Edited


Created By: Komal Charitra On 11/17/2022 at 10:20 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: 11/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/18/2022
Section Cited

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87309 Storage Space: (a) Disinfectants, cleaning solutions, poisons...which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

Violation of this regulation is evidenced by:
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During the visit, LPA observed the laundry room to have chemical and toxins cabinet unlocked and accessible to residents which poses an immediate health and safety risk to residents 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:Cara Smith
LICENSING EVALUATOR NAME:Komal Charitra
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022


LIC809 (FAS) - (06/04)
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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
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: 11/17/2022
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LPA observed four dogs at the facility; two of which are resident dogs and the other two are staff dogs. According to the Licensee, the two staff dogs stay in the staff room and the two resident dogs are with the residents or in the office. During the visit, LPA did not hear the dogs bark. LPA toured the physical plant and observed a shed being utilized as another office room. Fire clearance indicates that shed is able to be utilized as an office room as long as staff are not using it as a sleeping area. Licensee indicated no staff sleep in the shed.

LPA requests the following forms to be submitted to CCLD by 11/24/22:
-LIC308 Designation of Administrative Responsibility
-LIC500 Personnel Report
-LIC610E Emergency Disaster Plan
-Administrator Certificate

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: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
LIC809 (FAS) - (06/04)
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