<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415201950
Report Date: 01/26/2024
Date Signed: 01/26/2024 01:38:29 PM


Document Has Been Signed on 01/26/2024 01:38 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:ADVENT RESIDENTIAL HOMEFACILITY NUMBER:
415201950
ADMINISTRATOR:HELEN MALIG-ONFACILITY TYPE:
740
ADDRESS:617 FIFTH AVETELEPHONE:
(650) 216-0073
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94063
CAPACITY:15CENSUS: 9DATE:
01/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator - Helen Malig-OnTIME COMPLETED:
01:45 PM
NARRATIVE
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
On this day, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required 1 year annual inspection visit. LPA met with administrator Helen Malig-On and explained the purpose of today's visit.

LPA was allowed entry into the facility. This is a one level facility. Annual Fees are current. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored in the kitchen locked beneath the kitchen and basement area. Cleaning solutions are also locked in the basement area as well as in the storage areas behind the facility. Perishable and non-perishable food items are observed as in place. LPA observed the medications are locked in the kitchen. The first aid kit observed as complete with required items. LPA observed that the facility is equipped with full sprinkler system, fire extinguishers are placed through out the facility last inspected 08/23/2023, smoke detector/carbon monoxide detectors are observed in place as hardwired, and central heating system is functional. Sprinkler system is noted as being inspected on 10/2023 and this inspection is valid for 5 years. Facility contains two common bathrooms with showers and one resident room that has a personal half bath. There is a staff/visitor full bathroom located adjacent to the kitchen. PPE and additional food supplies are observed as in place in rear storage area outside of the facility. Laundry area is also observed as fully operational located in the outside storage areas of the facility. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Water temperature was measured at 110F. LPA observed several resident rooms at random and all rooms are observed as clean, free of odors, and contained all the required furniture per regulatory recommendation. LPA observed call system in place for resident use. Currently there are 3 hospice residents in the facility. The facility has a waiver for 4 hospice residents.

Continued on page 2...
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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: ADVENT RESIDENTIAL HOME
FACILITY NUMBER: 415201950
VISIT DATE: 01/26/2024
NARRATIVE
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
LIC809C - Required 1 Year

Fire/disaster drill record reviewed last taking place on 01/23/2024. LPA conducted record reviews for 3 residents and 3 staff. Present in the facility is 9 residents and 4 staff. LPA reviewed the records indicated and all files reviewed are current. Administrator certificate is observed as expired in 10/2023. According to the administrator she has submitted renewal items in August or September 2023. Facility does not handle resident monies.

The following updated forms are being requested to be received by 02/02/2024:

• LIC610E Emergency Disaster Plan
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• Updated administrator certificate
• LIC9020 Client Roster
• Certificate of Liability Insurance

There are no citations issued on this day.

Report is reviewed with administrator Helen.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2