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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221427
Report Date: 12/17/2024
Date Signed: 12/17/2024 03:16:41 PM

Document Has Been Signed on 12/17/2024 03:16 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:AVANTI ADULT SERVICESFACILITY NUMBER:
191221427
ADMINISTRATOR/
DIRECTOR:		SAMUEL ANUAKPADOFACILITY TYPE:
775
ADDRESS:60 NORTH DAISY AVENUETELEPHONE:
(626) 564-0191
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 131CENSUS: 36DATE:
12/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:17 PM
MET WITH:Armine Kim - Program Director TIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met Armine Kim with 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. Facility is located in a commercial area and consist of the following: a lobby, 3 offices, a conference room, an activity area, 4 classrooms, a dining area, a kitchen, 3 client restrooms, a computer room, a video/music room, and an isolation room.

LPA conducted a tour of facility with Armine Kim and observed the following:
Facility is in good repair indoor and outdoors. All areas were observed with sufficient lighting, and furnish to provide activities. An activity and outdoor schedule was observed posted. Dining area was observed clean. Kitchen is used to have cooking activities. Utensil, cooking kitchenware, and supplies were observed. Knives and cleaning supplies were observed locked or inaccessible to clients in care. Client bathrooms were observed and water temperature was tested between 110.3-112.8 degrees F., which is within the required 105-120 degrees F. Outdoor space was observed clean and free of debris with a shaded seating area. All passageways were clear and free of obstruction. No large bodies of water were observed. Licensing posters and personal rights were observed posted in a common area. Smoke/Carbon Monoxide detectors were observed.

LPA reviewed files for 5 clients and 5 staff. Client files were missing client #4-#5(C4-C5) medical assessment and TB test clearance and Client #'3(C3)'s TB test clearance. All clients are monitored by Frank D. Lanterman Regional Center, San Gabriel and ELA Regional centers and the facility maintains a staff: client ration of 1 staff per 3 clients. Staff files were reviewed to have the required training.

(CONTINUED ON LIC 809C)
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
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 12/17/2024 03:16 PM - It Cannot Be Edited


Created By: Mary G Flores On 12/17/2024 at 02:35 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: 12/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82069(a)
Client Medical Assessments
(a) Prior to or within 30 calendar days following the acceptance of a client, the licensee shall obtain a written medical assessment of the client that determines the licensee's ability to provide necessary health-related services to the client. The assessment shall be used in developing the Needs and Services Plan.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 5 clients files reviewed, C4-C5 do not have a medical assessment on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2024
Plan of Correction
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Administrator will submit a copy of C3-C4's medical assessment to the department by POC due date 12/27/24.
Type B
Section Cited
CCR
82069(b)(1)
Client Medical Assessments
(b) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 5 clients file reviewed, C3-C5 do not have TB test clearance on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2024
Plan of Correction
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Administrator will submit a copy of TB test clearance for C3-C5 to the department by POC due date 12/27/24.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2024


LIC809 (FAS) - (06/04)
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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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: AVANTI ADULT SERVICES
FACILITY NUMBER: 191221427
VISIT DATE: 12/17/2024
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LPA reviewed vehicles/transportation registration and driver's license information. Facility maintains a copy of plan of operation.
Infection control and emergency disaster plans were reviewed. Last fire drill was conducted on 10/17/24.

Facility is going under a change of Program Director (administrator) since June 2024. LPA advised current designee to submit to the department require documents by 12/24/24 for change of administrator. Current designee Armine Kim meets the educational requirements and 30 hours of training within the last 24 months.

Deficiencies were noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Armine Kim and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC809 (FAS) - (06/04)
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