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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601040
Report Date: 05/27/2022
Date Signed: 05/27/2022 11:14:59 AM

Document Has Been Signed on 05/27/2022 11:14 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
CCLD Regional Office, 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: DATE:
05/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator/Licensee, Maria ComfortTIME COMPLETED:
11:30 AM
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On May 27, 2022, Licensing Program Analyst (LPA) Komal Charitra, conducted an unannounced case management visit. LPA met with Licensee, Maria Comfort and explained the purpose of the visit.

During the complaint investigation 14-AS-20220412141821, LPA Charitra cited the facility for Section 87307(a)(2)Personal Accommodation and Services,as a result of the facility utilizing the garage attic as a sleeping area for staff. The facility’s plan of correction was to submit a new facility floor plan to CCLD to request for a new fire clearance.

On May 20, 2022, CCLD received the fire clearance request back from San Mateo Consolidated Fire Department, and it was indicated that the garage attic and the shed in the backyard is not a suitable living accommodation for staff. In addition, the fire department also indicated that the shed in the backyard is not a permitted structure. According to the Licensee, it was indicated that she immediately moved the staff members out of the shed in the backyard. Staff will no longer be permitted to sleep in the shed and it will be utilized as a storage/office room for the Licensee. In addition, the garage attic was observed to be used as a storage space.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with Maria Comfort; a copy of the report is provided with appeal rights.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 05/27/2022 11:14 AM - It Cannot Be Edited


Created By: Komal Charitra On 05/27/2022 at 10:33 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: 05/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/28/2022
Section Cited
CCR
87203

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87203 FIRE SAFETY: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

Violation of this regulation is not met as evidenced by:
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During the visit LPA Charitra observed the backyard shed and the garage attic. LPA did not observe any staff members sleeping. Licensee moved staff members out of the shed and found them an alternative living accomodation.
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Based on observations and information collected, the licensee did not compy with the section cited above, as the garage attic and backyard shed was being used by staff for sleeping, which poses an immediate health, safety, or personal rights risk to persons in care.
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HSC

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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:Julio Montes
LICENSING EVALUATOR NAME:Komal Charitra
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2022


LIC809 (FAS) - (06/04)
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