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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603471
Report Date: 03/09/2022
Date Signed: 03/09/2022 12:54:34 PM

Document Has Been Signed on 03/09/2022 12:54 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) 804-8216
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY: 4CENSUS: 4DATE:
03/09/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:07 AM
MET WITH:Bundi Nyaga TIME COMPLETED:
01:00 PM
NARRATIVE
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On the above date, Licensing Program Analysts (LPAs) Christine Wong, Bennette Pena and Ashley Calderon conducted an unannounced complaint investigation at the above facility. During the complaint investigation, LPA observed three staff (S1-S3) were not associated with the facility. LPA spoke to the administrator and he stated that he thought the association should be automatically transferred from the old license as the facility was licensed on 08/12/2021.

According to the California Code of Regulations (Title 22, Division 6, Chapter 1), LPA observed the following deficiency and issued a citation and assessed the civil penalty.

An exit interview was conducted and a copy of the Facility Evaluation Report and Appeal Rights were provided to Staff Belen Felia.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2022
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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Document Has Been Signed on 03/09/2022 12:54 PM - It Cannot Be Edited


Created By: Christine Wong On 03/09/2022 at 12:16 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: 03/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/10/2022
Section Cited
CCR
80019(e)(2)

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80019 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility. (2) Request a transfer of a criminal record clearance as specified in Section 80019(f)
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The administrator will ensure each staff get a transfer of criminal record recorance in the facility. The administrator will associate S1-S3 through guidian and send the copy to LPA by POC due date.
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The evidenced is not met as evidenced by record review. Staff#1, #2 and #3 were not assoicated with the facility which posed an immediate risk to the clients in care.
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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:Christine Yee
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2022


LIC809 (FAS) - (06/04)
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