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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601040
Report Date: 04/20/2022
Date Signed: 04/20/2022 10:06:48 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/12/2022 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20220412141821
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: 5DATE:
04/20/2022
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Licensee/Adminsitrator, Maria Comfort TIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Facility is utiziling the attic as a sleeping area for staff
INVESTIGATION FINDINGS:
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On April 20, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced 10-day complaint visit. LPA met with Licensee/Administrator, Maria Comfort, and explained the purpose of the visit.

Regarding the allegation that facility is utilizing the attic as a sleeping area for staff, according to the complainant, the garage attic is being used as a staff room for the male caregivers. During the visit, LPA toured the facility and observed the garage. LPA Charitra observed a wooden ladder leading to the attic. LPA and Licensee observed the attic room which had staff member's personal belongings and two mattresses. According to the Licensee, there were two male staff members who did sleep in the attic for about 6 months because they were live-in staff.

Based on LPA’s observation and interviews conducted, it was determined that facility is utilizing the attic as a sleeping area for staff. The preponderance of evidence standard has been met; therefore, the above allegation is determined to be Substantiated.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 9099D. Failure to correct the deficiencies may result in civil penalties.

Report was reviewed with Licensee, Maria Comfort, and a copy is provided with the appeals rights.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/12/2022 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20220412141821

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:
04/20/2022
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Licensee/Adminsitrator, Maria Comfort TIME COMPLETED:
10:30 AM
ALLEGATION(S):
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9
Facility is unsanitary
INVESTIGATION FINDINGS:
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On April 20, 2022, Licensing Program Analyst (LPA) conducted an unannounced 10-day complaint visit. LPA met with Licensee/Administrator, Maria Comfort, and explained the purpose of the visit.

Regarding the allegation that facility is unsanitary, according to the complainant, the Licensee allows visitors to bring their dogs into the facility and the dogs would pee and poop in the facility hallway. Based on LPA’s observations, the facility's hallways were clear from any clutter. LPA obsered 4 dogs at the facility; 2 were locked in the staff room and 2 were fenced in the side yard. There was no maladorous odor or fecal matter. Licensee indicated that if the dogs do have an accident, a staff member immediately cleans it up.

Therefore, based on observations and interviews conducted, the allegation that the facility is unsanitary is UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred.

Report was reviewed with Licensee, Maria Comfort, and a copy is provided with the appeals rights.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 14-AS-20220412141821
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 415601040
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/27/2022
Section Cited
CCR
87307(a)(2)
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87307(a)(2)Personal Accommodation and Services: Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to
provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply… Resident bedrooms shall be provided which meet, at a minimum, the following requirements… No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage storage area, shed or similar detached building…
Violation of this regulation is not met as evidence by:
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Licensee to submit a new floor plan to CCLD by due date to request for a new fire clearance
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Based on LPA's observations and interviews conducted, it was indicated that there was 2 live-in staff members who utilized the attic as a sleeping area which poses a potential health, safety or personal rights risk to persons 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.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3