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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210108757
Report Date: 08/18/2023
Date Signed: 08/18/2023 03:30:15 PM

Document Has Been Signed on 08/18/2023 03:30 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, 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: 7DATE:
08/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Staff Member, Henry Mattos TIME COMPLETED:
03:45 PM
NARRATIVE
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At approximately 9:30AM, Licensing Program Analysts (LPAs) Felias and Coppo arrived unannounced to conduct a Required 1 Year visit and met with Staff Member, Henry Mattos. Assistant Program Director, John Ahrens, arrived at approximately 10:15AM. Facility is an Adult Residential Home that provides care and assistance for Adults with Mental Health Diagnoses. Facility has an approved fire clearance and capacity for 8 Ambulatory Clients. Upon arrival, LPAs were informed there were currently 2 staff members on site.

At approximately 9:45AM, LPAs reviewed the Facility's Staff Roster. During review, LPAs discovered that Staff Member 1 (S1) was fingerprint cleared, but not associated to the facility as required. (See LIC9102, Technical Violation, Regulation 80019(e)). LPAs contacted the Regional Office and confirmed the fingerprint clearance and association status of S1. Facility provided LPAs with the association paperwork for S1, today, 08/18/2023. LPA confirmed with the Regional Office that the paperwork had been received.

**Assistant Program Director understands that a Civil Penalty is not being issued today for S1 because their association paperwork has been received by the Regional Office to be processed.**

At approximately 10:50AM, LPAs conducted a walk-though of the facility with Assistant Program Director. LPAs observed the following: The facility was found to be at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a single floor building, with 4 client bedrooms, 3 client bathrooms, a staff bedroom/bathroom, 2 office spaces, a kitchen, dining room, living room, and laundry/recreation area. Facility has a mitigation plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Mattress pads were in place or available for Client use. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit.

During walk-through LPAs observed that facility's Fire extinguishers were last inspected March 2022 (This Deficiency has been cited, see LIC809D, Regulation 80020(a)).

Continued on LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 08/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2023
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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Document Has Been Signed on 08/18/2023 03:30 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 08/18/2023 at 01:47 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: AVANTI
FACILITY NUMBER: 210108757

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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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Based on Observations and Interviews conducted, the Licensee did not comply with the section cited above. LPAs observed the following: Bathrooms were shown to have mold, needed floor repair, had water damage, and did not have trash cans with lids. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2023
Plan of Correction
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Licensee to submit self-certification that all identified areas of the facility will be cleaned and free of mold. Licensee to update Department on when flooring will be scheduled and completed. Licensee to submit photographic proof that bathrooms have been cleaned, that trash cans have lids and that the flooring has been replaced. Plan to be submitted to Department by POC due date of Saturday, 08/19/2023.
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on Observations made, the Licensee did not comply with the section cited above where all fire extinguishers located in the facility were shown to be last serviced March 2022. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2023
Plan of Correction
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Licensee to submit self-certication that they will contact Fire Department or Fire Safety company to have the fire extinguishers serviced and will submit a copy of invoice/receipt and pictures of newly dated tags to Department by POC date of 08/19/2023.
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:Kimberley Mota
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/18/2023 03:30 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 08/18/2023 at 01:47 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: AVANTI
FACILITY NUMBER: 210108757

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)(1)
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. (1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on Observations made, the Licensee did not comply with the section cited above. Spiders were seen in client rooms and under sinks. LPAs also observed dead insects on the window sills.This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2023
Plan of Correction
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Licensee to clean windows and ensure that all spiders and cobwebs are disposed of appropriately. Licensee to submit photographs to Department as proof by POC due date of 08/28/2023.
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:Kimberley Mota
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2023


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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: 08/18/2023
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Continued from LIC 809
Facility was found to be in slight disrepair. LPAs observed that the recreation area had a broken outlet face plate.
LPAs observed the following in the facility's bathrooms: 2 of 3 Client bathrooms were shown to have mold. 1 of 3 client bathrooms were in need of floor repair and had water damage. 3 of 3 bathrooms did not have trash cans with lids (These Deficiencies have been cited, See LIC809D, Regulation 80087(a)). LPAs also observed cleaning supplies/ toxins accessible to Clients located in a Client's bathroom. Staff immediately stored cleaning supplies inaccessible to clients in the staff room (See LIC9102, Technical Violation, Regulation 80087(g)). LPAs also observed spiders located under the facility sinks, and in client rooms (this Deficiency has been cited, see LIC809D, Regulation 80087(a)(1)). LPAs observed a cigarette butt located on a client's dresser. LPAs informed Assistant Program Director and Facility Staff of the potential fire hazard and discussed clients maintaining house rules by smoking and discarding cigarette butts appropriately in the designated outside area. LPAs observed that the facility had canned food that were either dented or expired. LPAs discussed with Assistant Program Director and Facility Staff about ensuring all canned goods are within the appropriate expiration period ((See LIC9102, Technical Assistance, Regulation 80076(a)(7)).

Facility has a hard wired fire alarm and sprinkler system that is directly connected to the local Fire Department. Smoke detectors and carbon monoxide detectors were last tested June 2023. The facility's last fire drill was conducted June 2023.
LPAs also discussed Administrator duties for the facility. At this time, the facility is being overseen by Regional Director, Connie Mann. Per conversation with Assistant Program Director, John Ahrens, he is to be the new Administrator for the facility. LPAs are requesting the following Administrator paperwork:
Administrator Documents
· LIC 308 (Designation of Facility Responsibility)
· Active and Current Administrator Certificate
· First Aid Certificate
· Administrator Resume
· LIC 500 (Personnel Report)
· LIC 501 (Personnel Record)
· LIC 503 (Health Screening Report - personnel)
· Proof of TB test
· LIC 9182 (Criminal Record Exemption Transfer Request)
· LIC 508 (Criminal Record Statement)
· Copy of Driver's License or Passport that is not expired
· Copy of Board of Directors' Resolution meeting minutes signed (required for all corporations)
Continued on LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023
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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: 08/18/2023
NARRATIVE
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Continued from LIC809C

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

**An immediate civil penalty in the total amount of $500.00 has been issued for a lack of fire clearance as required (See LIC421IM).**

LPAs unable to complete the Annual Inspection. Annual Continuation Visit to be conducted at a later date.

Exit interview conducted. Copy of report, LIC-809D (Deficiency Page), LIC9102 (Technical Advisory/Violation), LIC811 (Confidential Names), Plan of Corrections, and Appeal Rights discussed and provided to Team Leader. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023
LIC809 (FAS) - (06/04)
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