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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210108757
Report Date: 06/24/2022
Date Signed: 06/24/2022 11:12:14 AM

Document Has Been Signed on 06/24/2022 11:12 AM - 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:AVANTIFACILITY NUMBER:
210108757
ADMINISTRATOR:ASHKENAZY, REBECCAFACILITY TYPE:
735
ADDRESS:7 LE CLAIRE COURTTELEPHONE:
(415) 472-2875
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 8CENSUS: 8DATE:
06/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Mental Health Counselor I, Henry MattosTIME COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Avanti unannounced for the purpose of conducting a Required-1 year inspection. LPA was met at the door by, Mental Health Counselor I, Henry Mattos, and was granted access into the facility.

LPA conducted walk through of the facility with Mental Health Counselor I, Henry Mattos on this date and time. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on March 2022. Facility smoke detectors and Carbon Monoxide Detectors are hard wired to the fire station. Fire and Smoke Detectors will be scheduled in the coming weeks (See LIC 9102). There was a sufficient supply of both perishable and non-perishable foods as required by Title 22 Regulations. Food is available for clients any time of the day. There are daily activities available for clients. Toxins are locked and inaccessible to clients. There is a sufficient supply of cleaners, hygiene products and paper products available for clients. Toxins are stored in a locked cabinet inside the facility laundry room. Dangerous items were stored inaccessible to clients. Hot water temperature measured at 128 degrees falling out of Title 22 acceptable regulation of 105 to 120 degrees F in 2 of 3 client’s bathrooms while touring facility on June 24, 2022 (See LIC 809D). First aid kit was appropriate. There was a supply of cleaners, hygiene products and paper products available for clients. The bathroom designated for clients at the facility were supplied with individual paper towels; hand soap dispenser was available. All client’s bedrooms have lighting & appropriate furnishings, and beds are to be outfitted with mattress pads as required by Title 22 Regulations # 85088(c)(4).

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE supply stored in the Administrator office. Staff have had all PPE training required, but have not been N95 Fit tested.



(Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: AVANTI
FACILITY NUMBER: 210108757
VISIT DATE: 06/24/2022
NARRATIVE
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LPA requested the following documents:

LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
LIC 400- Affidavit regarding Client Cash Resources
Updated facility sketch
Updated Emergency Disaster Plan (LIC 610D)
Surety Bond
Most up-to-date Liability insurance
Control of Property
Register of clients

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted and appeal of rights provided to the Mental Health Counselor I, Henry Mattos.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/24/2022 11:12 AM - It Cannot Be Edited


Created By: Farhaan Sarangi On 06/24/2022 at 10:58 AM
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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: AVANTI
FACILITY NUMBER: 210108757

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (2) Taps delivering water at 125 degrees F (51.6 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 3 clients bathrooms had a water temperature exceeding 125 degrees with no visable warning signs displayed, which poses a potential health, safety or personal rights risk to clients in care.
POC Due Date: 07/01/2022
Plan of Correction
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Licensee shall correct the water temperature and/or display signs to warn clients of temperatures exceeding 125 degrees. In addition, Licensee shall submit a summary on how future compliance will be met moving forward.
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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2022


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