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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603491
Report Date: 08/18/2022
Date Signed: 08/18/2022 04:31:21 PM

Document Has Been Signed on 08/18/2022 04:31 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
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: 5DATE:
08/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:James BelcheffTIME COMPLETED:
04:43 PM
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At 10:35 a.m on 08/18/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. Clients and staff were at Day Program. LPA returned to the facility at 3:10 p.m. LPA met with Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out.

The facility was last visited on 07/30/2021 for an annual visit. It is a single story building with 4 bedrooms, 1 bathroom, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for 6 ambulatory residents. The front and back yards are maintained. The main entrance has a sign posted for the facility’s masking policy. LPA was screened for infectious disease upon entry. The screening station contained gloves, hand sanitizer, digital thermometer, and visitor log. The facility has 4 bedrooms. Bedroom #1 is a staff room, and other rooms are shared rooms. Clients were observed in their bedrooms during the visit. All bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition. Beds were at least 6 feet apart to provide social distance. The facility has 1 bathroom which contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, and a non-skid mat in the shower. At 4:05 p.m. LPA measured the water temperature to be 111.7 degrees Fahrenheit. LPA observed an adequate supply of perishable and non-perishable food. The kitchen has 2 refrigerators and 2 freezers. Sharps and cleaning solutions were locked near the kitchen. Facility postings include menu, facility license, house rules, and resident rights. An operable washer and dryer were located near the kitchen as well. Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. Board games and activities were stored in the hallway closets. Medications were locked near the dining room table. At 4:19 p.m. LPA measured the room temperature to be 80.8 degrees Fahrenheit. All emergency exit paths were free from obstructions. Exit gates were unlocked with inward facing latches. Emergency Disaster Plan posted in the kitchen. At 4:07 p.m. LPA tested the carbon monoxide detector to be operational. At 4:09 p.m. LPA tested the smoke detector to be operational. At 4:16 p.m. LPA observed a fully charged fire extinguisher in the kitchen. During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued. Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2022
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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