198603471-8-31-2023-28-AS-BTAO-CV8S3K-20230831133116

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603471
Report Date: 08/31/2023
Date Signed: 08/31/2023 01:31:22 PM

Document Has Been Signed on 08/31/2023 01:31 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	AVANI HOME		FACILITY NUMBER:	198603471
ADMINISTRATOR:	BUNDI NYAGA		FACILITY TYPE:	735
ADDRESS:	340 N WESTRIDGE AVE		TELEPHONE:	(626) 699-2138
CITY:	COVINA	STATE: CA	ZIP CODE:	91724
CAPACITY: 4		CENSUS: 4	DATE:	08/31/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:29 AM
MET WITH:	Bundi Nyaga, administrator		TIME COMPLETED:	01:30 PM

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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. Upon arrival, LPA met with administrator Bundi Nyaga, who assisted with the visit. The facility serves 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 12/27/24. Annual fees are current. LPA discussed with administrator and staff regarding the purpose of today's visit and the inspection.

During the visit, the new inspection CARE tool was used; a tour of the facility was conducted; food supply was reviewed; staff/clients files were reviewed; staff/clients interviews were conducted; and medications were reviewed.

The facility is a single family home 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 the required furniture and in compliance. Lamps/lights for each room are available. Adequate linen and personal hygiene supply are observed.

Hot water temperature was measured at 109.3 degrees Fahrenheit which was within Title 22 Regulation guidelines. Two days of perishable and seven days of nonperishable food supplies are observed.

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. (-continued in LIC 809C-)

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

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: 08/31/2023

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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 8/16/23.

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 Administrator and report LIC 809s are provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

LIC809 (FAS) - (06/04)

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