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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508904
Report Date: 08/30/2024
Date Signed: 08/30/2024 03:54:15 PM

Document Has Been Signed on 08/30/2024 03:54 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ASCENSION HOMEFACILITY NUMBER:
410508904
ADMINISTRATOR/
DIRECTOR:
NELIA G. ASUNCIONFACILITY TYPE:
735
ADDRESS:1908 JEFFERSON AVENUETELEPHONE:
(650) 364-5069
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94062
CAPACITY: 6CENSUS: 2DATE:
08/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Nelia Asuncion, Administrator/LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On August 30, 2024, Licensing Program Analysts (LPAs) Kiran Jain and John Calandra arrived at the facility at 1:45 PM to conduct the Annual 1-year required inspection. LPAs Jain and Calandra met with Administrator/Licensee, Nelia Asuncion and House Manager, Ludy Pantaleon and explained the purpose of the visit.

LPAs Jain and Calandra toured the physical plant. This is a 1-story building with 4 bedrooms, 2 bathrooms, kitchen with dining, and living room. No accessible bodies of water or hazards were observed. The fire extinguisher was fully charged. The smoke detector and carbon monoxide detector were fully operational.

The kitchen sink water temperature was measured at 106°F. No expired food items were observed. The facility had the required 7-days of non-perishables and 2-days of perishables items.

All rooms were observed to be clean with sufficient furniture and lighting. The hot water temperature in the bathroom sink faucet was measured at 105°F.

Sharp objects, detergents, poisons, and soap were observed to be accessible to persons in care. In the presence of the LPAs, they were locked and are no longer accessible to persons in care.

LPAs reviewed 2 resident files and 2 staff files. All were observed to be complete.

The client’s medications were securely stored in a locked cabinet. Medication administration records (MARs) were reviewed and found to match Centrally Stored Medication Records kept at the facility. The First Aid kit was checked and found to have the required items.

No deficiencies were cited during today's visit. The Annual will be completed at a later date.

An exit interview was conducted. This report was reviewed with Nelia Asuncion, Administrator/Licensee and a copy of this report was left at the facility.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2024
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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