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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601040
Report Date: 01/27/2023
Date Signed: 01/27/2023 12:18:15 PM

Document Has Been Signed on 01/27/2023 12:18 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:
01/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Licensee/Administrator, Maria ComfortTIME COMPLETED:
12:26 PM
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On January 27, 2023, 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 screened at entry point and Licensee asked LPA to sign the visitor log. Licensee was able to provide screening documentation for visitors, staff and residents.

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, 1 shower room and 1 full bathroom. LPA observed the two staff room to be clean. Two dogs were observed in one of the staff rooms. LPA observed extra linen stored in facility closet. The full bathroom was observed to be equipped with liquid soap, paper-towels and a trash can with a fitted lid. LPA observed the shower room to be equipped with a non-skid mat. All 6 resident rooms were observed to be clean and clear from any tripping hazards. Half-baths were in good repair and odorless. During the visit LPA observed 3 residents watching television in the dining room while maintaining social distancing.

LPA observed the laundry room door to be locked. LPA toured the laundry room and observed washer and dryer to be in good working condition. Toxins, chemicals, and medications were observed to be locked and stored appropriately and inaccessible to residents. Living room and dining room were observed to be clean and free from tripping hazards. A comfortable temperature is maintained and lighting is sufficient for comfort. COVID-19 signage was observed to be posted throughout the facility.

LPA toured the kitchen and observed 2 day perishable and 7 day non-perishable. Kitchen was observed to be equipped with liquid soap and paper-towels. During the visit, the facility cook was preparing lunch for the residents. Sharps were observed to be locked and stored away. LPA observed two additional refrigerators located in the garage with extra food. Extra canned food was present as well. First aid kit was observed to be completed. 30-day PPE supply was present. LPA observed facility office room to have two more dogs. At the time of the visit, LPA did not hear any dogs being disruptive to visitors, staff or residents.

No citations are issued during this visit. LPA reviewed report with Licensee and a copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2023
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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