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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221427
Report Date: 01/26/2022
Date Signed: 01/26/2022 01:27:52 PM

Document Has Been Signed on 01/26/2022 01:27 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:AVANTI ADULT SERVICESFACILITY NUMBER:
191221427
ADMINISTRATOR:SAMUEL ANUAKPADOFACILITY TYPE:
775
ADDRESS:60 NORTH DAISY AVENUETELEPHONE:
(626) 564-0191
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 131CENSUS: 25DATE:
01/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Armine Kim - Area Director TIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced annual visit at the facility with focus in the infection control domain. LPA Flores met with Armine Kim Area Director and explained the reason for the visit.

The facility is licensed as an Adult Day Program with a capacity to serve 131 clients of which 20 may be non-ambulatory. All clients are monitored by Frank D. Lanterman Regional Centers and the facility maintains a staff: client ration of 1 staff per 3 clients. Facility has a lobby, 3 offices, a conference room, an activity area, a dinning area, a kitchen, 3 client restrooms, a computer room, a video room, an isolation room, and a shaded patio.

LPA Flores conducted a tour of the facility with Armine Kim Area Director and observed the following:
Building, and classrooms, and equipment are in good condition. Cleaning solutions in kitchen are kept in a cabinet to the left of the sink with a child proof lock that was not properly locked during the visit.
Restrooms are in working condition and water temperature was tested in men's restroom at 124 degrees F., in women's restroom at 125 degrees F., and in activity room's restroom at 61.3 degrees F. which is not within the required 105 - 120 degrees F.
Last fire drill was conducted on 10/21/21. LPA Flores reviewed 2 staff/ 2 participants files.

Facility is following COVID guidelines regarding screening visitors/staff/participants, posting of social distancing/hand washing/mask were observed in lobby, restrooms, and throughout the facility, isolation room was observed no covered trash cans were observed in isolation area, PPE supplies were observed for at least 30 days, Per Pasadena Department of Public all staff in direct contact with participants/clients must wear a proper mask and face shield/googles. Per PIN 21-10ASC Staff must be fit for N95 mask.
Deficiencies were provided on LIC 809D and Technical Advisories Notes during this visit.
Exit interview was conducted with Armine Kim Area Director and a copy of this report was provided.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2022
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 6
Document Has Been Signed on 01/26/2022 01:27 PM - It Cannot Be Edited


Created By: Mary G Flores On 01/26/2022 at 12:34 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: AVANTI ADULT SERVICES
FACILITY NUMBER: 191221427

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82087(a)(3)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (3) Disinfectants, cleaning solutions, poisons, 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 as cleaning solutions, and disinfecting solutions were observed unlocked in kitchen cabinet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/27/2022
Plan of Correction
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Area Director will ensure that all cleaning supplies are maintain lock at all times by certifying in LIC 9098, licensee will provide an in service training, submit LIC 9098, photographs of correction, and copies of in-service training by 1/27/22.
Type A
Section Cited
CCR
82088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures 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 3 out of 3 restrooms water temperature tested out of the required 105 - 120 degrees F. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/27/2022
Plan of Correction
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Licensee will ensure facility maintatins water temperature within 105 -120 degrees F at all times, will submit LIC 9098 by 1/27/22 and will keep a water temperature log for the next 7 days and submit a copy to department by 2/2/22.
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:Rebecca Orendain
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2022


LIC809 (FAS) - (06/04)
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