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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603491
Report Date: 09/23/2022
Date Signed: 09/23/2022 04:00:57 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/16/2022 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20220916125350
FACILITY NAME:AMIGO HOME IIFACILITY NUMBER:
197603491
ADMINISTRATOR:ELIZABETH BIJOUFACILITY TYPE:
735
ADDRESS:23601 VANOWEN STREETTELEPHONE:
(818) 888-1983
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:6CENSUS: 6DATE:
09/23/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Elizabeth BijouTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff failed to treat resident with dignity and respect
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent complaint visit to finish investigation into the allegation above. LPA met with the administrator and explained the reason for this visit.
Staff failed to treat resident with dignity and respect
It is alleged that staff # 1 (S1) was saying inappropriate things to client #1 (C1) by calling C1 names and using vulgar language. LPA conducted a previous visit on 9/20/22 where LPA interviewed facility staff. During today's visit LPA interviewed C1 and other clients in the facility from 1:15-3:00pm. Information obtained through interviews revealed that S1 did have an incident where they said disparaging remarks towards C1. When the administrator was made aware of the incident C1 was removed from the facility and has since been terminated from their position. Based on the information obtained through interviews this allegation is deemed Substantiated at this time. Deficiency cited on LIC 9099 D. Appeal Rights explained. Exit Interview conducted.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 31-AS-20220916125350
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMIGO HOME II
FACILITY NUMBER: 197603491
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/23/2022
Section Cited
CCR
80072(a)(1)
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Personnel Rights-each client shall have personal rights which include, but are not limited to, the following: To be accorded dignity in his/her personal relationships with staff and other persons.
This requirement was not met as evidenced by:
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Corrected before visit. S1 was removed from their position and is no longer working at the facility.
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Based on interviews conducted S1 spoke inappropriately to C1 which posed a potential health and safety risk to 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.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/16/2022 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20220916125350

FACILITY NAME:AMIGO HOME IIFACILITY NUMBER:
197603491
ADMINISTRATOR:ELIZABETH BIJOUFACILITY TYPE:
735
ADDRESS:23601 VANOWEN STREETTELEPHONE:
(818) 888-1983
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:6CENSUS: 6DATE:
09/23/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Elizabeth BijouTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
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5
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7
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9
Residents don't feel safe at the facility
INVESTIGATION FINDINGS:
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5
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13
Licensing Program Analyst (LPA) Wendell Smith conducted a subsequent complaint visit to finish investigation into the allegation above. LPA met with the administrator and explained the reason for the visit.

Regarding the allegation above it is alleged that clients at the facility did not feel safe around staff #1 (S1). LPA conducted the initial visit on 9/20/22 and conducted interviews with facility staff. During today's visit LPA conducted interviews with facility clients regarding this allegation from 1:15-3pm. Interviews revealed that five out of six clients interviewed felt safe with S1 working at the facility. Based on the information obtained through interviews this allegation is deemed Unsubstantiated at this time. Exit Interview conducted.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3