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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208913
Report Date: 02/06/2023
Date Signed: 02/06/2023 11:31:53 AM


Document Has Been Signed on 02/06/2023 11:31 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, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:ADVENT RESIDENCE HOMEFACILITY NUMBER:
157208913
ADMINISTRATOR:ASIGNACION, JEANFACILITY TYPE:
740
ADDRESS:10114 STONEHAM STTELEPHONE:
(661) 695-9152
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY:6CENSUS: 6DATE:
02/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Administrator, Jean AsignacionTIME COMPLETED:
11:45 AM
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On 02/06/2023, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and was granted entry to the facility. Facility staff contacted Administrator, Jean Asignacion, who arrived a short time later.

LPA conducted a facility tour with Administrator. COVID-19 guidelines are not in place. Facility appeared cleaned. LPA observed multiple bikes, a basketball court, bed frames, multiple pieces of wood and other items blocking the self-latching gate and emergency exit door in the dining area. Hand sanitizer was readily available to residents and visitors at facility entrance. Social distancing is maintained in the common and dining areas. Bathrooms did not have trash cans with lids. Hand washing posters were not observed by the bathroom sink. Bedrooms are single occupant. There is one shared bedroom, beds in the shared bedroom observed to be at least 6 feet apart.

LPA checked residents' medications and observed a 30-day supply. Food supply was checked and there appeared to be an adequate supply. Cleaning and PPE supplies were checked. Facility staff were not observed to be wearing facial coverings. Resident’s files had updated emergency contact information.

LPA is requesting the following documents be submitted to the Fresno CCL office by 02/20/2023: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2023
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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: ADVENT RESIDENCE HOME
FACILITY NUMBER: 157208913
VISIT DATE: 02/06/2023
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LPA is requesting Administrator submit a copy of the facility's mitigation plan by 5:00PM today, 02/06/2023.

A deficiency is being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D.

Exit interview conducted and a plan of correction was reviewed and developed with Administrator. A copy of this report and appeal rights were discussed and provided to Administrator, Jeaan Asignacion, whose signature on this form confirms receipt of this document.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 02/06/2023 11:31 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: ADVENT RESIDENCE HOME
FACILITY NUMBER: 157208913

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
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.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when LPA observed multiple objects blocking the emergency exit in the dining room and the path to the exit gate which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/07/2023
Plan of Correction
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Licensee agrees to remove all objects and submit proof to the Fresno CCL office by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2023
LIC809 (FAS) - (06/04)
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