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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601040
Report Date: 01/17/2023
Date Signed: 01/17/2023 09:45:08 AM

Document Has Been Signed on 01/17/2023 09:45 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:
01/17/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Licensee/Administrator, Maria ComfortTIME COMPLETED:
10:00 AM
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On January 17, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management- plan of correction (POC) visit to verify and to confirm that the facility is in compliance with the citation that was issued on 12/23/22. LPA Charitra met with Licensee/Administrator, Maria Comfort and explained the purpose of the visit.

On 12/23/22, the facility was cited for California Code of Regulation (CCR) 87303(a) Maintenance and Operation. During the visit, LPA toured the facility and observed four dogs present; two of which were in the Licensee's room and the other two were in the Licensee's office. There were no dogs observed in the common areas of the facility during the visit. Licensee provided LPA a copy of training log documentation in relation to how the facility can stay in compliance with CCR 87303(a).

Report is reviewed with Licensee and a copy is provided. No citations are issued during the visit.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2023
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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