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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600784
Report Date: 10/21/2022
Date Signed: 10/25/2022 11:14:09 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/25/2022 11:14 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:ADVENT RESIDENTIAL HOME IIFACILITY NUMBER:
415600784
ADMINISTRATOR:MUNCADA, EDITHAFACILITY TYPE:
740
ADDRESS:808 HAWTHORNE WAYTELEPHONE:
(650) 689-5690
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY:7CENSUS: 7DATE:
10/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Allyssa Lumen and Edith LumenTIME COMPLETED:
03:45 PM
NARRATIVE
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LPA Audrey Jeung toured facility and grounds, consisting of 6 client bedrooms and 4 full bathrooms--3 are for client use. Administrator resides in detached garage, that has been renovated as living space with 2 sleeping rooms. Clothes washer and dryer are located in semi-enclosed structure attached to outside of kitchen/dining area. There is a detached storage shed in back yard. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. Liquid soap is available at all sinks. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There are 7 residents present, and 2 staff, plus a new caregiver who is "shadowing;" the administrator arrived during the visit. Two residents are receiving hospice services. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, including current first aid training and health screenings. Edith Muncada is a certified RCFE administrator (x 8/24) that oversees facility operations.

The following information/forms are requested to be submitted to CCLD BY 11/4/22:
- Administrative Organization (LIC309)
- Designation of Administrative Responsibility (LIC308)
- Personnel Report (LIC500)
- Emergency Disaster Plan (LIC610E)
- Proof of current Liability Insurance
- Proof of control of property/current signed lease agreement
- Infection Control Plan per CCR 87470

Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on a following page.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2022
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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Document Has Been Signed on 10/25/2022 11:14 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: ADVENT RESIDENTIAL HOME II
FACILITY NUMBER: 415600784

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/24/2022
Section Cited

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PERSONAL ACCOMMODATIONS SERVICES
All outdoor and indoor passageways and stairways shall be kept free of obstruction.
This requirement is not met, as exit door from private bathroom in room #1--which is identifed by sign and included on facility sketch--cannot be fully opened because of ramp railing. One cannot exit down ramp because ramp is too narrow.
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Licensee failed to ensure that exit can be used for exiting., which poses an immediate health and safety risk for clients in care.
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Type A
10/24/2022
Section Cited

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PERSONAL RIGHTS OF RESIDENTS IN ALL FACILITIES
Residents in all RCFEs shall have the personal right to be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met, as protocols for COVID screening of visitors, staff and clients
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is not in place. Visitors are not screened & asked for contact number, daily record of COVID screening/temp checks for staff and clients is not maintained. Licensee failed to ensure that COVID safety protocols are maintained, which poses an immediate health, safety or personal rights risk to clients in care.
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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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 10/25/2022 11:14 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: ADVENT RESIDENTIAL HOME II
FACILITY NUMBER: 415600784

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/24/2022
Section Cited

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ADMINISTRATOR QUALIFICATIONS DUTIES
Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. .
This requirement was not met, as 3 staff present upon LPA's arrival were unable to find PPE, client files, emergency contacts.
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Licensee failed to ensure that staff is competent to meeet the needs of clients, which poses an immediate health, safety, or personal rights risk to clients in care.
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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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3