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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603471
Report Date: 08/26/2022
Date Signed: 08/26/2022 12:33:35 PM

Document Has Been Signed on 08/26/2022 12:33 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:AVANI HOMEFACILITY NUMBER:
198603471
ADMINISTRATOR:AMANYA, HERBERT BAGOROFACILITY TYPE:
735
ADDRESS:340 N WESTRIDGE AVETELEPHONE:
(626) 699-2138
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY: 4CENSUS: 4DATE:
08/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Leonard Kanyi, staffTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. Upon arrival, LPA met with Leonard Kanyi, staff, who assisted with the visit. LPA spoke with Administrator, Herbert Amanya over the phone during the visit. The facility is to serve four (4) ambulatory clients, age 18 through 59 years old. All current clients were placed by San Gabriel/Pomona Regional Center. Administrator certificate is current and expires on 02/20/24. LPA discussed with administrator and staff regarding the purpose of today's visit and the inspection.

During the visit, the following domain of the new inspection tool was used: infection control domain; a tour of the facility was conducted; food supply was reviewed; and medications were reviewed.

This is a single story home which consists of four (4) clients bedrooms, two (2) bathrooms, dining room with activity area, kitchen, living room, laundry room, attached garage, and patio with a covered patio area. Facility maintains the required two (2) days perishable and seven (7) days non- perishable. Clients’ bedrooms have beds, dresser, and closet space available. Adequate linen and personal hygiene supply are observed. Lamps/lights for each room are available to ensure the safety and comfort of all persons in the facility. Hot water temperature was measured at 117.3 degrees Fahrenheit which was within Title 22 Regulation guidelines. (-Continued in LIC 809C-)

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: AVANI HOME
FACILITY NUMBER: 198603471
VISIT DATE: 08/26/2022
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Smoke detectors and carbon monoxide detectors are dual and operable. Medications are centrally stored and locked. Medications are properly logged and current. Hazardous items are locked and inaccessible to clients. Fire extinguisher is fully charged. Pesticides/poisons are not stored in food areas, kitchen, or where kitchen equipment/utensils are stored. The front yard is well maintained. No pools or large bodies of water at the facility. Passageways are free of obstruction. Last disaster drill is conducted on 07/20/22.

No deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6. An exit interview was conducted.

This report was discussed with staff, Leonard at the facility and Administrator over the phone. The report LIC 809s are provided to staff Leonard, whose signature on this form confirm receipt of these documents.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
LIC809 (FAS) - (06/04)
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