Haven@22nd Avenue Assisted Living

On 12/16/2025, 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 6 residents and 3 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. There are no hospice residents at this time. 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 112F in resident room half bath. There are two fire extinguishers in the facility that is observed with inspection tags of 09/15/2025. Continued on next page... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Page 2 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 3 residents in care at the facility. Based on review of all resident files, and medications all items are current and logged accurately. Staff files are reviewed, and of the reviewed files conducted randomly, staff files are current and associated appropriately and have current finger print clearances. Last fire/disaster drill was conducted on 05/15/2025 per records reviewed. Administrator certificate is observed to be current expiring of 08/31/2026. The following updated forms are requested to be submitted to CCLD by 01/14/2026 : • Copy of updated administrator certificate • LIC308 Designation of responsible staff person • LIC500 Staff Schedule There are no citations issued during today's inspection visit. Report is reviewed with Maria and a copy is provided on this day.

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. Continued on next page... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Page 2 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.

On February 8, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA met with Administrator, Maria Comfort and explained the purpose of the visit. LPA toured the facility inside and outside including all of resident rooms, common areas & kitchen. The indoor and outdoor passageways were free of obstruction. No accessible bodies of water of fire safety hazards observed. Extra linen was observed. LPA toured all six single resident rooms with half bathrooms in each room and observed them to clean with all required furniture. Two staff rooms were observed. LPA observed one full bathroom and one main shower room to be clean and free from odor. A comfortable temperature of 69 degrees F is maintained and lighting is sufficient for comfort. Hot water was also tested between 105-115 degrees F throughout the facility. Sharps, toxins and medication were locked and inaccessible to residents. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current as of February 2023. LPA observed 2 days for perishables and 7 days non-perishables. Emergency drills are logged and done every three months. LPA to return back to the facility in the future to review staff and resident records. No citations were issued during this visit. LPA reviewed report with Administrator and a copy is provided.

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.

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.

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 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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.