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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508904
Report Date: 07/01/2022
Date Signed: 07/01/2022 12:27:35 PM

Document Has Been Signed on 07/01/2022 12:27 PM - 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:ASCENSION HOMEFACILITY NUMBER:
410508904
ADMINISTRATOR:NELIA G. ASUNCIONFACILITY TYPE:
735
ADDRESS:1908 JEFFERSON AVENUETELEPHONE:
(650) 364-5069
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94062
CAPACITY: 6CENSUS: 3DATE:
07/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Nelia AsuncionTIME COMPLETED:
12:30 PM
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On this day at , Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced infection control annual inspection. LPA met with licensee Nelia Asuncion and explained purpose of today's inspection.

LPA toured the physical plant inside and out. There are no accessible bodies of water or fire safety hazards observed. COVID postings and hand washing signs are present inside the facility but not on the main entrance. Hand sanitizer is observed as readily available through out the facility. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is observed as in place. Medications, toxins and sharps are stored appropriately and inaccessible to clients. Facility ambient temperature is warm and comfortable, and lighting is sufficient for residents and staff safety. Toilet and bathing facilities are equipped with grab bars and non-slip flooring material. Liquid soap is available. Paper towels present in common bathroom in hallway. Water temperature is tested in hallway bathroom at 105F. First-aid kit is inspected and is complete. A Disaster and Mass Casualty Plan is present. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been finger print cleared and associated to the facility. Administrator certificate is viewed as current expiring 12/23/2022. Mitigation plan is reviewed with the administrator.

The following updated forms are requested to be submitted to CCLD by 07/08/2022:

• Copy of administrator Certificate
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• LIC 610D Emergency Disaster Plan
• LIC 400 Affidavit Regarding Client Cash Resources
• LIC 402 Surety Bond

LPA provided technical assistance today on attached LIC9102.
No deficiencies cited today.


Reports are reviewed with licensee.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2022
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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