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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603471
Report Date: 07/26/2024
Date Signed: 07/26/2024 04:30:28 PM

Document Has Been Signed on 07/26/2024 04:30 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/
DIRECTOR:		BUNDI NYAGAFACILITY TYPE:
735
ADDRESS:340 N WESTRIDGE AVETELEPHONE:
(626) 699-2138
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY: 4CENSUS: 4DATE:
07/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Bundi Nyaga, administratorTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. Upon arrival, LPA met administrator Bundi Nyaga who assisted with the visit. The purpose of today's annual inspection was discussed. 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.

During the visit, the new inspection CARE tool was used; physical plant was conducted; food supply/ staff/clients files /medication were reviewed; and staff/clients interviews were conducted.

The facility was 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 maintained the required two (2) days perishable and seven (7) days non- perishable. Clients’ bedrooms had the required furniture and in compliance. Hot water temperature was measured at 106.5 degrees Fahrenheit which was within Title 22 Regulation guidelines.

Smoke detectors and carbon monoxide detectors were dual and operable. Medications were centrally stored and locked. Medications were properly logged and current. Hazardous items were locked and inaccessible to clients. Fire extinguisher was fully charged. Pesticides/poisons were not stored in food areas, kitchen, or where kitchen equipment/utensils were stored.

Deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6. See LIC 9099 D for deficiency.

An exit interview was conducted. This report was discussed with the administrator and report LIC 809 along with the appeal rights were provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2024
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 07/26/2024 04:30 PM - It Cannot Be Edited


Created By: Bonnie Tao On 07/26/2024 at 02:11 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: AVANI HOME
FACILITY NUMBER: 198603471

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2024

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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LPA and administrator Bundi observed live cockroaches crawled across the countertop in the facility kitchen.

Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2024
Plan of Correction
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Licensee agreed to hire pest control company to manage the pest problem until the facility was free of cockroaches.
Administrator will provide LPA with detailed reports until the facility is cleared of the pest issue. The administrator would ensure to comply with all recommendations given by pest control company if that is needed. Due on POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2024


LIC809 (FAS) - (06/04)
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