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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415201849
Report Date: 07/18/2025
Date Signed: 07/18/2025 02:39:10 PM

Document Has Been Signed on 07/18/2025 02:39 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:EAST WEST CARE REDWOOD CITY IIFACILITY NUMBER:
415201849
ADMINISTRATOR/
DIRECTOR:		CYNTHIA ADVINCULAFACILITY TYPE:
740
ADDRESS:1018 CLINTON STREETTELEPHONE:
(650) 261-3593
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY: 8CENSUS: 8DATE:
07/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Emma Advincula, CaregiverTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
NARRATIVE
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On 7/18/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct the Annual 1-year required inspection. LPA Calandra was greeted by Emma Advincula, Caregiver and explained the purpose of the visit. Administrator, Cyndi Advincula arrived later during the visit.

LPA Calandra toured the physical plant. This is a one-story building with 8 bedrooms, 2 bathrooms, living room, kitchen, and dining room. All bedrooms had the required furniture and sufficient lighting. All bathrooms had anti-skid floor mats and grab bars. No accessible bodies of water or hazards were observed. The fire extinguisher was fully charged. The smoke detector and carbon monoxide detector were observed to be in working order. Per interview with Administrator, Cyndi Advincula, the facility's smoke alarms and carbon monoxide detectors are connected directly to the fire department. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. The facility's hot water temperature was measured within the 105-120 degrees Fahrenheit. The facility had 7 days of non-perishables and 2 days of perishables on hand. No food was expired.

All sharp objects, detergents, poisons, and soap were observed to be locked and in-accessible to persons in care.

LPA reviewed 5 resident records and 6 staff files. All staff files were observed to be complete but resident files were missing documents.

During review of resident files, LPA observed that resident, R1 had been diagnosed with Dementia but had not had a reappraisal since 2023. Furthermore, LPA observed during file review that all resident records were missing both the Functional Capabilities Assessment and the Pre-Admissions Appraisal.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: John Calandra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: EAST WEST CARE REDWOOD CITY II
FACILITY NUMBER: 415201849
VISIT DATE: 07/18/2025
NARRATIVE
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Type B citations were provided for these violations.

A review of Centrally Stored Medications showed that all medications were properly labeled and that dosages and times of day were recorded by the facility.

During today's inspection LPA received the following documents:
  • Liability insurance

LPA has requested the facility send a copy of their LIC 500: Personnel Summary Report by Friday, July 25th.
Deficiencies are cited under the California Code of Regulations, Title 22. Failure to correct the deficiencies by the due date may result in civil penalties.

An exit interview was conducted. This report was reviewed with facility representative and a copy of the report along with appeal rights left at the facility.

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: John Calandra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/18/2025 02:39 PM - It Cannot Be Edited


Created By: John Calandra On 07/18/2025 at 02:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: EAST WEST CARE REDWOOD CITY II
FACILITY NUMBER: 415201849

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(17)(A)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (A) Section 87457, Pre-Admission Appraisal;

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not have a pre-admission appraisal for R1, R2, R3, R4, and R5, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2025
Plan of Correction
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Licensee will complete a pre-admission appraisal for all residents in care.
Type B
Section Cited
CCR
87506(b)(17)(B)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (B) Section 87459, Functional Capabilities;

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not have a Functional Capabilities Assessment for R1, R2, R3, R4, and R5, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2025
Plan of Correction
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Licensee will complete a functional capabilities assessment for each resident.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
John Calandra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/18/2025 02:39 PM - It Cannot Be Edited


Created By: John Calandra On 07/18/2025 at 02:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: EAST WEST CARE REDWOOD CITY II
FACILITY NUMBER: 415201849

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Type B
Section Cited
CCR
87463(b)
(b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not have a reappraisal for resident, R1 who has been diagnosed with Dementia and requires an annual reappraisal, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2025
Plan of Correction
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Licensee will reappraise R1 and send a copy of the reappraisal to the Department.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
John Calandra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2025


LIC809 (FAS) - (06/04)
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