Haven@22nd Avenue Assisted Living

Type of visit: Required - 1 Year

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.the state’s words, verbatim · CDSS document, Jan 27, 2023

Type of visit: Case Management - Other

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.the state’s words, verbatim · CDSS document, Jan 17, 2023

Allegation investigated: -Facility staff are not following COVID-19 guidelines -Facility does not have sufficient staff -Facility staff are not trained -Facility dogs bit a visitor

On December 23, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver findings for the above allegations. LPA met with Licensee/Administrator, Maria Comfort and explained the purpose of the visit. LPA was screened at entry point. Regarding the allegation that facility staff are not following COVID-19 guidelines, according to the reporting party, he/she was not screened at the front door nor was his/her temperature taken upon arrival. During the investigation, LPA interviewed Licensee and reviewed the visitor screening log documentation. According to the Licensee, she hired new staff and the staff were aware that visitors needed to be screened upon arrival, however the Licensee acknowledged that the staff did not check the visitor's temperature upon arrival that day due to staff being distracted. Regarding the allegation that facility does not have sufficient staff, according to the reporting party, the Licensee admitted she is short-staffed and is constantly working. During the investigation, LPA interviewed the Licensee and reviewed the LIC500 (Personnel Report). According to the Licensee, it was acknowledged, she does not have enough staff and is trying to hire more caergivers. In addition, LPA visited the facility on 12/20/2022 and 12/23/2022, and the Licensee and the Licensee's sister was the only staff present for the six residents, however the Licensee indicated that her sister does not assist residents in care. CONT. TO 9099C Substantiated Regarding the allegation that facility staff are not trained, according to the reporting party, the Licensee admitted she short-staffed and the new staff are not trained. In addition, according to the reporting party, the Licensee's sister who is the assigned facility cook is not trained. During the investigation, LPA reviewed training records and interviewed the Licensee. According to the Licensee, it was acknowledged that the new staff present were trained regarding COVID-19 protocols and screening procedures and was given training log documentation. In addition, LPA requested training documentation for the Licensee's sister, however, the Licensee was unable to provide LPA training documentation for her sister who handles the resident's food. Regarding the allegation that the facility dogs bit a visitor, according to the reporting party, on 12/8/22, he/she visited the facility and a caregiver opened the door with two dogs barking at his feet. In addition, the reporting party indicated that the dogs bit his/her legs. During the investigation, LPA interviewed the Licensee and the Licensee admitted the day of the incident, she had two new staff members present at the facility and they were not aware that they needed to put the dogs in the room prior to opening the front door. The Licensee indicated that the dogs bit the visitor and provided the visitor with the dogs rabies shots. Animal control was called and the dogs were quarantined for 10 days. Based on the information collected and interviews conducted, it was determined that the preponderance of evidence standard has been met; therefore, the above allegations are 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 is reviewed with Licensee and a copy is provided with appeals rights.the state’s words, verbatim · CDSS document, Dec 23, 2022 · control 14-AS-20221214141018

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Dec 30, 2022

87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations... Violation of this regulation is evidenced by: Based on record revieed and interviews, the facility failed to check visitor's temperature on 12/8/22. In addition, according to the Licensee, it was acknowledged that the new staff were unaware to check visitor's temperature upon arrival.the state’s words, verbatim · CDSS document, Dec 23, 2022

Plan of correction: Licensee to conduct in-service training regarding COVID-19 protocols and screening procedures.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Dec 30, 2022

87411 Personnel Requirements - General: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... Violation of this regulation is evidenced by: Based on record reviewed and interviews conducted, it was noted that the Licensee is the only one providing care to six residents. In addition, the Licensee acknoweldged she is short-staffed and is trying to hire more caregivers.the state’s words, verbatim · CDSS document, Dec 23, 2022

Plan of correction: Licensee to submit a plan to how facility can meet CCR 87411(a) by due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(1) · Plan of correction due date: Dec 30, 2022

87411 Personnel Requirements: (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance...(1) Principles of good nutrition, good food preparation and storage, and menu planning. Violation of this regulation is evidenced by: Based on records reviewed, the Licensee failed to provide training to the facility cook in relation to food preparation and proper food handling.the state’s words, verbatim · CDSS document, Dec 23, 2022

Plan of correction: Licensee to conduct in-service training for food handling and preparation and submit LPA a copy by due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Dec 30, 2022

87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times...for the safety and well-being of residents, employees and visitors. Violation of this regulation is evidenced by: Based on the interview conducted, the Licensee admitted that on 12/8/22 the facility dogs bit a visitor because the facility staff failed to put the dogs away in a room prior to allowing visitors in.the state’s words, verbatim · CDSS document, Dec 23, 2022

Plan of correction: Licensee will conduct in-service training with staff regarding putting dogs away prior to opening the door to visitors and will submit a copy of the training log to CCLD by 12/30/22.

Type of visit: Case Management - Deficiencies

On December 23, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit in relation to a complaint (complaint control # 14-AS-20221214141018). LPA met with Licensee/Administrator, Maria Comfort and explained the purpose of the visit. During a complaint investigation; complaint control #14-AS-20221214141018, the Licensee indicated she is assisting a resident transfer with a hoyer lift by herself. During the visit, LPA requested records of hoyer lift training. According to the Licensee, she has done any training with the nurse regarding hoyer lifts , however was unable to provide records. Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with Licensee and a copy is provided with appeals rights.the state’s words, verbatim · CDSS document, Dec 23, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(c) · Plan of correction due date: Dec 30, 2022

87412 Personnel Records: (c) Licensees shall maintain in the personnel records verification of required staff training and orientation. Violation of this regulation is evidenced by: Licensee failed to provide hoyer lift training.the state’s words, verbatim · CDSS document, Dec 23, 2022

Plan of correction: Licensee will take trainings regarding hoyer lifts and conduct an in-service training with caregivers on how to properly operate a hoyer lift by due date.

Type of visit: Required - 1 Year

On November 17, 2022, 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 not screened at entry point and Licensee was unable to provide LPA screening log documentation for visitors and staff, however was able to provide COVID screening log documentation for residents. According to the Licensee, staff and visitor's temperatures are taken but is not being documented. 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, and 2 full bathrooms. LPA observed the two staff room to be clean. One of the full bathrooms were observed with liquid soap, paper-towels and a trash can with a fitted lid. LPA advised Licensee to remove bath-towels, hand-towels and bar soaps. LPA observed extra linen present. LPA toured the facility with the Licensee and observed living room and dining room to be clean and free from any tripping hazards. A comfortable temperature of 66 degrees F is maintained and lighting is sufficient for comfort. During the visit, LPA observed 2 residents having breakfast and 1 resident watching television. LPA toured 6 resident rooms and all were observed to be private rooms with half-baths in each room. All rooms and bathrooms were clean and odor-free. LPA observed the second bathroom to be a resident shower room. LPA toured the kitchen and observed 2 day perishable and 7 day non-perishable. Sharps were observed to be locked and inaccessible to residents. LPA advised Licensee to remove hand-towels from the kitchen. LPA toured the garage and observed extra food supply present. LPA observed a storage room above the garage. 30-day PPE supply was present. LPA observed the laundry room to have a washer and dryer in good repair. Medications were observed to be locked in a cabinet in the laundry room, however chemicals and toxins were observed to be unlocked. According to the Licensee, staff were using the chemicals to wash clothes. Licensee locked the chemicals and toxins in LPA's presence. LPA observed office room with two dogs. CONT. TO 809C LPA observed four dogs at the facility; two of which are resident dogs and the other two are staff dogs. According to the Licensee, the two staff dogs stay in the staff room and the two resident dogs are with the residents or in the office. During the visit, LPA did not hear the dogs bark. LPA toured the physical plant and observed a shed being utilized as another office room. Fire clearance indicates that shed is able to be utilized as an office room as long as staff are not using it as a sleeping area. Licensee indicated no staff sleep in the shed. LPA requests the following forms to be submitted to CCLD by 11/24/22: -LIC308 Designation of Administrative Responsibility -LIC500 Personnel Report -LIC610E Emergency Disaster Plan -Administrator Certificate Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with Licensee and a copy is provided with appeals rights.the state’s words, verbatim · CDSS document, Nov 17, 2022

From the deficiency page — Deficiency type: Type A · Plan of correction due date: Nov 18, 2022

87309 Storage Space: (a) Disinfectants, cleaning solutions, poisons...which could pose a danger if readily available to clients shall be stored where inaccessible to clients. Violation of this regulation is evidenced by: During the visit, LPA observed the laundry room to have chemical and toxins cabinet unlocked and accessible to residents which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 17, 2022

Type of visit: Case Management - Other

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.the state’s words, verbatim · CDSS document, May 27, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: May 28, 2022

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: 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.the state’s words, verbatim · CDSS document, May 27, 2022

Plan of correction: 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.

Allegation investigated: Facility is utiziling the attic as a sleeping area for staff

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. Substantiatedthe state’s words, verbatim · CDSS document, Apr 20, 2022 · control 14-AS-20220412141821

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(2) · Plan of correction due date: Apr 27, 2022

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: 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.the state’s words, verbatim · CDSS document, Apr 20, 2022

Plan of correction: Licensee to submit a new floor plan to CCLD by due date to request for a new fire clearance