415600784-1-2-2024-14-AS-KHOS-CZALVW-20240108080614

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600784
Report Date: 01/02/2024
Date Signed: 01/02/2024 06:24:41 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/12/2022 and conducted by Evaluator Audrey Jeung

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20221012091342

FACILITY NAME:	ADVENT RESIDENTIAL HOME II		FACILITY NUMBER:	415600784
ADMINISTRATOR:	MUNCADA, EDITHA		FACILITY TYPE:	740
ADDRESS:	808 HAWTHORNE WAY		TELEPHONE:	(650) 689-5690
CITY:	MILLBRAE	STATE: CA	ZIP CODE:	94030
CAPACITY:	7	CENSUS: 6	DATE:	01/02/2024
		UNANNOUNCED	TIME BEGAN:	05:00 PM
MET WITH:	Allyssa Lumen and Criselea Carig		TIME COMPLETED:	06:30 PM

ALLEGATION(S):

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- Staff spoke inappropriately to resident
- Staff handle resident in a rough manner
- Staff do not use the appropriate equipment to transfer resident resulting in injury to resident
- Staff did not inform resident's authorized representative of resident’s injuries

INVESTIGATION FINDINGS:

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LPA Jeung interviewed resident.

Based on client records reviewed and interviews with client and staff, these allegations are determined to be unsubstantiated. Not enough information was provided to conduct a more thorough investigation.

Client #3 moved out in November 2022 after facility issued 30-day notice.

Although the allegations may have occurred or are valid, there is not enough evidence to prove the alleged
violations did or did not occur.

Unsubstantiated

Estimated Days of Completion:

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

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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