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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200110
Report Date: 01/16/2025
Date Signed: 01/16/2025 04:54:30 PM

Document Has Been Signed on 01/16/2025 04:54 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:AVANCARE ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
079200110
ADMINISTRATOR/
DIRECTOR:		CESAR REDOLOSO IIIFACILITY TYPE:
735
ADDRESS:2100 CRISTINA WAYTELEPHONE:
(925) 308-7586
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 4DATE:
01/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Veronica Pimentel, Direct Care StaffTIME VISIT/
INSPECTION COMPLETED:
05:10 PM
NARRATIVE
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On 01/16/2025 at 12:50PM AM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Caregiver, Veronica Pimentel and explained the purpose of the visit. House Manager/Care Staff, Romel Diomampo arrived later. The facility’s fire clearance was approved for 6 Ambulatory clients.

LPA toured the facility with Romel Diomampo including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of three (3) bathrooms, five (5) total bedrooms which four (4) bedrooms are occupied by the clients and one (1) bedroom is occupied by staff All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 72- degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 130.1 degrees Fahrenheit. All toilets, hand washing stations, and bathing stations are safe, sanitary and in operating condition. The supply of extra hygiene’s was available for clients. There is a minimum of 7-day supply of non-perishables and 2-day perishables food supply.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 11/05/2024. First aid kit was observed to be complete. Fire drill was last conducted on 11/09/2024. Emergency Disaster Plan last reviewed on 10/31/2023.


Continue on LIC809C
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: AVANCARE ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 079200110
VISIT DATE: 01/16/2025
NARRATIVE
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Continued from LIC809.

Five (5) staff records were reviewed, and all staff have first aid certification. All Six (6) clients' records reviewed, current, and complete.

The following forms to be updated and submitted to CCLD by 01/23/2025:

· Liability insurance.
· Surety Bond
· LIC308 (Designation of facility Responsibility)
· LIC400 Affidavit Regarding Client/Resident Cash Resources
· Emergency disaster plan (9 pages)
· Updated LIC500 (Personnel Report)
· Updated facility sketch


LPA observed the following deficiencies:
  • At 1:12PM, LPA observed rodent droppings in clients chest of drawers in bedroom
  • At 1:15PM, LPA observed water temperature in shared bathroom was measured at 103.1 Degree Fahrenheit.
  • At 1:19PM, LPA observed Arm and Hammer laundry detergent in unlocked laundry room.
  • At 1:23PM, LPA observed Clorox Bleach, Lysol disinfectant spray, Arm and Hammer laundry detergent, Windex window cleaner, Paint and Primmer, Ant and Roach spray, wood stain, Fabuloso, multipurpose cleaner, commercial drain cleaner and lighter fluid in unlocked garage.
  • At 1:33PM, LPA observed both (emergency and side gate had locks on them.

Exit interview conducted a copy of this report, LIC421IM, and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 01/16/2025 04:54 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 01/16/2025 at 04:08 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: 01/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in having Arm and Hammer laundry detergent in unlocked laundry room which poses an immediate health, safety risk to persons in care.
POC Due Date: 01/17/2025
Plan of Correction
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House Manager/Care Staff immediately locked laundry room door. Deficiency cleared during visit.

Type A
Section Cited
CCR
87309(a)
87309 Storage Space
(a)Disinfectants, cleaning solutions, poisons, firearms, and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.


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 in having Clorox Bleach, Lysol disinfectant spray, Arm and Hammer laundry detergent, Windex window cleaner, Paint and Primmer, Ant and Roach spray, wood stain, Fabuloso multipurpose cleaner, commercial drain cleaner and lighter fluid in unlocked garage. which poses an immediate health, safety risk to persons in care.
POC Due Date: 01/17/2025
Plan of Correction
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House Manager/Care Staff immediately locked garage door. Deficiency cleared during visit.
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:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/16/2025 04:54 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 01/16/2025 at 04:08 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: 01/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in having rodent droppings in clients' chest of drawers which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2025
Plan of Correction
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Administrator will implement a permanent plan on how to prevent rodents/vermin entering the facility and send CCLD a copy of invoice from pest control agency by POC date.
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 in having hot water temperature measured at 130.1 which poses a potential health, safety or risk to persons in care.
POC Due Date: 01/23/2025
Plan of Correction
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Administrator agreed to adjust water temperature and send CLLD an email photo of water temperature meeting regulation by POC date.
LPA also advised care staff place a hot water sign in bathrooms.
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:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 01/16/2025 04:54 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 01/16/2025 at 04:30 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: 01/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
80020 Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.
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 by locking emergency and side gate without fire clearance for locked parameter which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/17/2025
Plan of Correction
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Staff removed lock during inspection. Deficiency cleared.
Civil penalty of $500 is being assessed.

Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


LIC809 (FAS) - (06/04)
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