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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603471
Report Date: 09/21/2022
Date Signed: 09/21/2022 11:03:50 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/15/2022 and conducted by Evaluator Bonnie Tao
COMPLAINT CONTROL NUMBER: 28-AS-20220915111317
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:
09/21/2022
UNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Bundi Nyaga, house manager
Herbert Amanya, administrator		TIME COMPLETED:
11:20 AM
ALLEGATION(S):
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Staff did not dispense medication as prescribed by physician.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Tao and Ramirez conducted an unannounced complaint visit to the facility. Upon arrival, LPAs met with Bundi Nyaga, house manager and spoke with Herbert Bagoro Amanya, Administrator over the phone. LPAs explained the purpose of the visit to staff.

During today's visit, LPAs obtained a copy of the Staff/Client roster, client#1’s file and client#1’s medical records. The investigation consisted of staff interview and client file review.

In regards to the allegation, “staff did not dispense medication as prescribed by physician”, it is alleged that, on 09/08/22, client#1 (C1) had a medication, Clonidine 0.3mg, which needed to be taken 1 tablet by mouth at 8am was not dispensed at 8am and C1 had already left to day program. The investigation revealed that client#1’s medication records, dated 09/08/22, indicated medication, Clonidine 0.3mg for client #1 was not dispensed in the morning as prescribed.
(- Continue to LIC9099C -)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 28-AS-20220915111317
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/21/2022
NARRATIVE
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Interview with Staff #1 confirmed C1's medication, Clonidine 0.3mg was not dispensed to C1 on 09/08/22 in the morning.

Based on LPAs' file review and interview, the investigation revealed that the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.

Exit interview conducted with Bundi Nyaga, house manager, and a copy of this report and appeal rights provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20220915111317
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/22/2022
Section Cited
CCR
80075(b)(5)(C)
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A record of each dose is maintained in the client's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the client's response.

This requirement is not met evidenced by:
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Licensee shall provide:
(1) additional medication administration training to all staff and provide proof to the department;
(2) review Title 22, Section 80075(b)(5)(C) and provide a signed statement indicating the review of this section detailing how to
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Medication records review and interview revealed that on 09/08/22, medication, Clonidine 0.3mg at 8 am for Client #1 was not dispensed as prescribed.
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prevent future medication errors on shift by the POC date
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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.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3