Community Care Licensing

SUPERVISOR'S NAME: Cara Smith TELEPHONE: (650) 266-8800 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 01/02/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2024

Document Has Been Signed on 01/02/2024 06:13 PM - It Cannot Be Edited

FACILITY NAME: ADVENT RESIDENTIAL HOME II	FACILITY NUMBER: 415600784
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/02/2024

Type A

Section Cited

CCR

87202(a)(2)

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on client record review, the licensee did not comply with the section cited above, as two out of 6 residents are deemed to be BEDRIDDEN, per MD reports, but facility is not approved for bedridden residents and does not maintain fire clearance for bedridden clients. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/03/2024
	Plan of Correction
1 2 3 4	Plan of correction to be submitted to CCLD BY DUE DATE.

Type A

Section Cited

CCR

87355(e)(3)

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on staff record review, the licensee did not comply with the section cited above, as night staff #2 does not have criminal record clearance associated to this facility. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/03/2024
	Plan of Correction
1 2 3 4	Criminal record clearance transfer request for staff #2 to be submitted to CCLD with photo ID BY DUE DATE, or transfer of clearance to be done in Guardian.

SUPERVISOR'S NAME: Cara Smith TELEPHONE: (650) 266-8800 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 01/02/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2024

Document Has Been Signed on 01/02/2024 06:13 PM - It Cannot Be Edited

FACILITY NAME: ADVENT RESIDENTIAL HOME II	FACILITY NUMBER: 415600784
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/02/2024

Type B

Section Cited

CCR

87411(f)

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on staff record review, the licensee did not comply with the section cited above, as health screening and/or TB test results are not maintained for staff 2, #4, #6, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/16/2024
	Plan of Correction
1 2 3 4	Proof of health screenings and /or TB test results for S2, S4, S6 will be sent to CCLD BY DUE DATE

SUPERVISOR'S NAME: Cara Smith TELEPHONE: (650) 266-8800 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 01/02/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2024

Document Has Been Signed on 01/02/2024 06:13 PM - It Cannot Be Edited

FACILITY NAME: ADVENT RESIDENTIAL HOME II	FACILITY NUMBER: 415600784
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/02/2024

Type B

Section Cited

CCR

87411(c)(1)

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on staff record review, the licensee did not comply with the section cited above, as staff #2, #3, #6 do not have proof of current first-aid training, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/16/2024
	Plan of Correction
1 2 3 4	Proof of valid first aid training for S2, S3, S6 will be submitted to CCLD BY DUE DATE

Type B

Section Cited

HSC

1569.69(b)

(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on staff record review, the licensee did not comply with the section cited above, as medication staff #4 has not received annual medication training since 2/2022, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/16/2024
	Plan of Correction
1 2 3 4	Proof of current medication training for staff #4 will be sent to CCLD BY DUE DATE

SUPERVISOR'S NAME: Cara Smith TELEPHONE: (650) 266-8800 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 01/02/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2024

Document Has Been Signed on 01/02/2024 06:13 PM - It Cannot Be Edited

FACILITY NAME: ADVENT RESIDENTIAL HOME II	FACILITY NUMBER: 415600784
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/02/2024

Type B

Section Cited

CCR

87507(a)

(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on client record reviews, the licensee did not comply with the section cited above, as admission agreements for all clients are missing or incomplete, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/16/2024
	Plan of Correction
1 2 3 4	Completed admission agreements will be maintained on file for all residents, and administrator or designee will submit certification to CCLD BY DUE DATE that agreements are maintained on file

Type B

Section Cited

CCR

87465(h)(5)

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as clients' medications are pre-poured 10 days in advance. Seven-day pill organizers are observed, as well as plastic baskets containing small plastic cups for each clients' AM, PM, BT medications for 3 additional days. This practice poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/16/2024
	Plan of Correction
1 2 3 4	This practice must CEASE IMMEDIATELY, and proof/certification of correction to be submitted to CCLD BY DUE DATE

SUPERVISOR'S NAME: Cara Smith TELEPHONE: (650) 266-8800 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 01/02/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2024

Document Has Been Signed on 01/02/2024 06:13 PM - It Cannot Be Edited

FACILITY NAME: ADVENT RESIDENTIAL HOME II	FACILITY NUMBER: 415600784
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/02/2024

Type B

Section Cited

HSC

1569.625(b)(2)

(b) (1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. (2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of staff training, the licensee did not comply with the section cited above, as there is no evidence of required 20 hours of staff training for staff 1, 2, 3, 4, 6, including 8 hours of dementia training and 4 hours specific to postural supports, restricted health conditions and hospice care. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/16/2024
	Plan of Correction
1 2 3 4	Proof of required staff training for S1, S2, S3, S4, S6 will be submitted to CCLD BY DUE DATE.

SUPERVISOR'S NAME: Cara Smith TELEPHONE: (650) 266-8800 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 01/02/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2024

Document Has Been Signed on 01/02/2024 06:13 PM - It Cannot Be Edited

FACILITY NAME: ADVENT RESIDENTIAL HOME II	FACILITY NUMBER: 415600784
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/02/2024

Type B

Section Cited

CCR

87608(a)93)

POSTURAL SUPPORTS A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on client record review, the licensee did not comply with the section cited above, as ALL residents have bed rails--hospice client #4 has FULL bed rails. There are no MD orders for half bed rails and hospice care plan for client #4 does not include full bed rails. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/16/2024
	Plan of Correction
1 2 3 4	Proof of correction to be submitted to CCLD BY DUE DATE.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Cara Smith TELEPHONE: (650) 266-8800 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 01/02/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2024