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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415201950
Report Date: 01/08/2025
Date Signed: 01/08/2025 11:19:52 AM

Document Has Been Signed on 01/08/2025 11:19 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ADVENT RESIDENTIAL HOMEFACILITY NUMBER:
415201950
ADMINISTRATOR/
DIRECTOR:		HELEN MALIG-ONFACILITY TYPE:
740
ADDRESS:617 FIFTH AVETELEPHONE:
(650) 216-0073
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94063
CAPACITY: 15CENSUS: 7DATE:
01/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator, Helen Malig-On TIME VISIT/
INSPECTION COMPLETED:
11:28 AM
NARRATIVE
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On January 8, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA met with Administrator, Helen Malig-On and explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, common areas & kitchen. The indoor and outdoor passageways were free of obstruction. No accessible bodies of water of fire safety hazards observed. Living room and dining room was observed to be clean, free from tripping hazards and odor-free. A comfortable temperature of 72 degrees F is maintained and lighting is sufficient for comfort. LPA toured kitchen and observed two day perishable and seven day non-perishables. Sharps, chemicals and medications were observed to be locked an inaccessible to residents.

LPA toured 9 resident rooms;all of which were observed to be private rooms. All rooms were observed to be clean with required furnishings. LPA observed 2 full bathrooms and 1 half bathrooms. Bathrooms were observed to be clean and odor-free. Water temperature throughout the facility measured between 100-123 degrees F. Extra linen was observed to be present. First aid kit was observed to be complete and present.

LPA toured the garage and observed washer to be in good repair. Carbon monoxide monitor is working properly. All fire extinguishers have been checked and current as of September 2024. Emergency drills are logged and being conducted every three months.

LPAs reviewed 4 resident records and 4 staff records. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic requirement, however LPA observed 3/5 staff members first aid training to be expired. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

Deficiency found today under Title 22, Division 6, on following page LIC 809D. LPA reviewed report with administrator and a copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2025
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 3
Document Has Been Signed on 01/08/2025 11:19 AM - It Cannot Be Edited


Created By: Komal Charitra On 01/08/2025 at 11:10 AM
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: ADVENT RESIDENTIAL HOME
FACILITY NUMBER: 415201950

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff records reviewed, 3/5 staff members providing care and supervision to residents at the facility have expired first aid/CPR training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/09/2025
Plan of Correction
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Administrator shall submit training enrollment for the CPR training/ First aid training for all three staff members by 1/9/24
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:April Cowan
LICENSING EVALUATOR NAME:Komal Charitra
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2025


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/08/2025 11:19 AM - It Cannot Be Edited


Created By: Komal Charitra On 01/08/2025 at 11:10 AM
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: ADVENT RESIDENTIAL HOME
FACILITY NUMBER: 415201950

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, water temperature throughout the facility measure between 100-123 degrees F which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/15/2025
Plan of Correction
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Administrator to ensure facility water temperature is within 105-130 degrees F and provide LPA photos for proof
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:April Cowan
LICENSING EVALUATOR NAME:Komal Charitra
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2025


LIC809 (FAS) - (06/04)
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