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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600784
Report Date: 07/24/2024
Date Signed: 07/24/2024 02:01:43 PM


Document Has Been Signed on 07/24/2024 02:01 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 HOME IIFACILITY NUMBER:
415600784
ADMINISTRATOR:MUNCADA, EDITHAFACILITY TYPE:
740
ADDRESS:808 HAWTHORNE WAYTELEPHONE:
(650) 689-5690
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY:7CENSUS: 7DATE:
07/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator - Editha MuncadaTIME COMPLETED:
02:30 PM
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On 07/23/2024, Licensing Program Analyst (LPA) Jaime Vado and conducted an unannounced annual inspection visit. LPA met with administrator Editha Muncada and explained the purpose of today's visit.

LPA was allowed entry into the facility. This is a single level facility. All residents are approved to be non-amblatory and 2 hospice residents. There are 2 residents on hospice at this time. The physical plant was toured inside and outside of the facility 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 and locked in the kitchen in a drawer adjacent to the facility stove. Medications are observed to be locked in a kitchen cabinet. Perishable and non-perishable food items are observed as in place. Refrigerator is observed as having both lights out inside the freezer and main refrigerator. Additionally the lower refrigerator drawers and bins are broken or not in place leaving some fresh food supplies exposed and leftover food is not labeled with dates. This can pose a potential health and safety risk. Cleaning supplies are observed to be locked beneath kitchen sink. First aid kit is observed as complete with required items. LPA observed that there are multiple fire extinguishers in place last inspected 08/06/2021, smoke detectors, carbon monoxide detectors are observed in place through out the facility, facility is equipped with full fire sprinklers through out, and central heating system including and fans for facility use. PPE supplies and linen supplies are in place. Laundry area is also observed as fully operational in an exterior shed. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Facility does not have a record for conducting an emergency which can pose a potential health and safety. Water temperature was measured at 115F in a common bathroom in the hallway connecting to resident rooms.

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SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024
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 II
FACILITY NUMBER: 415600784
VISIT DATE: 07/24/2024
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LPA observed resident rooms at random and all appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. Client linen supplies are observed as in place.

The following updated forms are requested to be submitted to CCLD by 07/31/2024:

• Copy of updated Administrator Certificates
• LIC308 Designation of responsible staff person
• LIC610E Emergency Disaster Plan
• LIC500 Staff Schedule
• Copy of control of property or current lease

Technical violations are issued and attached on the following LIC9102 pages.

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

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC809 (FAS) - (06/04)
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