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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210108757
Report Date: 09/14/2023
Date Signed: 09/14/2023 03:25:03 PM

Document Has Been Signed on 09/14/2023 03:25 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:
09/14/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Staff Member, Steven Pozzi, and Assistant Program Director, John AhrensTIME COMPLETED:
03:30 PM
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At approximately 12:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Required 1 Year visit and met with Staff Member, Steven Pozzi. Assistant Program Director, John Ahrens, arrived later during visit at approximately 1:30PM. 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, LPA were informed there were 7 Clients in care with 1 client out of the community and 1 staff member on-site.

At approximately 12:25PM, LPA reviewed staff files, client files, client medications, and P&I monies. Staff and Client files were found to be organized and thorough. During Review, LPA observed that 1 of 7 client files did not have a Medical Assessment and that 6 of 7 client files did not have a Functional Capabilities Assessment (See Technical Violations, Regulation 80069(b) and Regulation 85068.2(b)(1)(F)). Staff have current First Aid/CPR certifications. Client Medications were centrally stored and secure. P&I Monies were found to be documented, secure and not commingled.

LPA is requesting the following documents to update the facility file:
  • Affidavit regarding Client/Resident Cash Resources (LIC400)
  • Designation of Facility Responsibility (LIC308)
  • Emergency Disaster Plan (LIC610D)
  • Updated Personnel Report (LIC500)
  • Surety Bond (LIC 402)
  • Register of Clients/Residents (LIC9020)
Facility Documents to be submitted to Community Care Licensing (CCL) by due date of Saturday, 10/14/2023.

No Deficiencies cited during visit.

Exit interview conducted. Copy of report, LIC9102 (Technical Advisory/Violation), discussed and provided to Assistant Program Director. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2023
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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