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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200110
Report Date: 01/04/2022
Date Signed: 01/04/2022 04:31:10 PM

Document Has Been Signed on 01/04/2022 04:31 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:AVANCARE ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
079200110
ADMINISTRATOR:CESAR REDOLOSO IIIFACILITY TYPE:
735
ADDRESS:2100 CRISTINA WAYTELEPHONE:
(925) 308-7586
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 6DATE:
01/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Cesar Redoloso III - Administrator TIME COMPLETED:
05:10 PM
NARRATIVE
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On 01/4/2022 Licensing Program Analyst (LPA) Leslie Ibo conducted an infection control annual inspection and explained the purpose of the visit with S3 , staff called Administrator Cesar Redoloso III, Administrator arrived around 3:15PM . LPA observed 6 clients during the visit. Facility has a completed mitigation plan. LPA inspected the facility inside and outside. LPA observed COVID-19 signage posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing.

Infection control designated leader is the Administrator. There was at least 7 days of nonperishable and 2 days of perishable foods. A certified administrator is on site a minimum of 20 hours a week to oversee proper business operation. Smoke and Carbon monoxide detectors were operational.


Continued on next page LIC 809-C...
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2022
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 01/04/2022 04:31 PM - It Cannot Be Edited


Created By: Leslie Ibo On 01/04/2022 at 04:10 PM
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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AVANCARE ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 079200110

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303
87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic
This requirement is not met as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above LPA observed side gate with locked and cannot be open immediately which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/04/2022
Plan of Correction
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Administrator corrected deficiency during inspection. Padlock on main security exit gate was removed. Cleared on the visit
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/04/2022 04:31 PM - It Cannot Be Edited


Created By: Leslie Ibo On 01/04/2022 at 04:12 PM
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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AVANCARE ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 079200110

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80065(f)(5)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. (5) Recognition of early signs of illness and the need for professional assistance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and records review the licensee did not comply with the section cited above in staff have not conducted staff training on infection prevention, symptoms, transmission and PPE use which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/14/2022
Plan of Correction
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Administrator stated he will train staff on the following topics infection prevention, symptoms, transmission and PPE use
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2022


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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: AVANCARE ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 079200110
VISIT DATE: 01/04/2022
NARRATIVE
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LPA observed the following:

· Facility has NOT conducted staff training on infection prevention, symptoms, transmission and PPE use.

· Staff are not FIT tested, administrator stated that he will look for fit testing kit or find a facility where he can send staff for n95 fit testing.

· LPA observed side gate was locked using padlock, corrected on the visit.


Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with Cesar Redeloso III.

Exit interview conducted and appeal rights and copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022
LIC809 (FAS) - (06/04)
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