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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601040
Report Date: 01/07/2025
Date Signed: 01/07/2025 12:12:30 PM

Document Has Been Signed on 01/07/2025 12:12 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:HAVEN@22ND AVENUE ASSISTED LIVINGFACILITY NUMBER:
415601040
ADMINISTRATOR/
DIRECTOR:		COMFORT, MARIAFACILITY TYPE:
740
ADDRESS:304 22ND AVETELEPHONE:
(415) 519-1110
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 6CENSUS: 5DATE:
01/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator/Licensee - Maria ComfortTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 01/07/2024, Licensing program Analyst (LPA) Jaime Vado conducted an unannounced required - 1 year inspection. LPA met with Administrator/licensee Maria Comfort and explained the purpose of today’s visit. Currently there are 5 residents and 4 staff present including the administrator.

This is a single level facility with 6 bedrooms for residents. The facility is licensed for age 60 and over; 6 Non-Ambulatory residents only; Hospice waiver granted for 2 residents. LPA Vado toured the facility both inside and outside with Maria. All outdoor and indoor passageway are free and clear of obstructions for emergency exit routes in case of fire or emergency. Facility's ambient temperature is comfortable for residents and LPA. No pools or bodies of water were observed during today's visit on the premises. LPA observed fresh food supplies and emergency one week of nonperishable and two (2) days of perishable foods as in place. There are refrigerators with freezers located in the garage and kitchen. Canned food supplies are primarily observed as stored in the garage. Knives are locked in the kitchen in a drawer next to the stove. Lunch is being prepared during today's visit. Toxic chemicals are stored in the laundry room in upper cabinets. Cleaning supplies and laundry soaps and items are also locked in these cabinets. PPE and incontinence supplies are observed to be in place in case of any use. Medications are locked in the laundry room in upper cabinets as well separate from the cleaning and supplies. Each client room observed contained the required furniture as outlined in regulations. Facility has functioning smoke detectors and carbon monoxide detectors. The facility is equipped with private half bathes in each resident room and a common shower room is located in the hallway. All are observed in good working order for resident use. Water temperature is tested at 111F. There are two fire extinguishers in the facility that is observed with inspection tags of 09/12/2024.


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SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: HAVEN@22ND AVENUE ASSISTED LIVING
FACILITY NUMBER: 415601040
VISIT DATE: 01/07/2025
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LPA observed resident linen supplies and incidentals also store in a hallway closet. Shower room floor is equipped with non-skid mats when in use. LPA inspected the medications and files of all 5 clients in care at the facility. Based on review of all resident files, and medications all items are current and logged accurately. Facility administrator certificate is observed as current expiring 01/13/2025. Last fire/disaster drill was conducted on 09/13/2024 per records reviewed. Administrator certificate is observed to be expired as of 08/31/2024. According to Maria she has already submitted the items for renewal.

The following updated forms are requested to be submitted to CCLD by 01/14/2025:

• Copy of updated administrator certificate
• Copy of facility's liability insurance
• LIC308 Designation of responsible staff person
• LIC610E Emergency Disaster Plan
• LIC500 Staff Schedule
• Copy of control of property or copy of lease

There are no citations issued during today's inspection visit.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
LIC809 (FAS) - (06/04)
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