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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210108757
Report Date: 08/22/2024
Date Signed: 08/22/2024 12:57:57 PM


Document Has Been Signed on 08/22/2024 12:57 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
SANTA ROSA RO, 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:
08/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Staff Member, Steve Pozzi, and House Manager, Nakuia MorrisTIME COMPLETED:
12:00 PM
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At approximately 9:05AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Staff Member, Steve Pozzi and House Manager, Nakuia Morris. Program Director, John Ahrens, arrived during visit at approximately 9:35AM. 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 was informed there were 7 clients in care and 2 staff members on site.

At approximately 9:15AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 9:25AM, LPA conducted a walk-though of the facility with House Manager. LPA observed the following: Facility was 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 bathrooms, a staff bedroom/bathroom, 1 office space, and common spaces. Facility has an Infection Control 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. Toxins were observed to be stored inaccessible to clients. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility's fire extinguishers were last inspected August 2023. Per House Manager, fire extinguishers are scheduled for inspection by the end of the month. Facility smoke detectors and carbon monoxide detectors were tested and operational. Facility's last emergency drill was conducted August 2024.

LPA reviewed staff files, client files, and resident medication. All files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. During medication review, LPA observed that all routine medications were observed to be appropriately centrally stored, but "as needed" medications or PRNs were not centrally stored as required (see technical violation, LIC9102, regulation 80075(k)). Administrator's Certificate for John Ahrens (7031309735) is current with an expiration date of 07/16/2025.

Continued on LIC809C

SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: AVANTI
FACILITY NUMBER: 210108757
VISIT DATE: 08/22/2024
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Continued from LIC809

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 09/22/2024.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report, LIC9102 (Technical Advisory/Violation), discussed and provided to Program Director and House Manager. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC809 (FAS) - (06/04)
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