<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603491
Report Date: 07/07/2023
Date Signed: 07/07/2023 02:01:07 PM

Document Has Been Signed on 07/07/2023 02:01 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,
, CA
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:
07/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Elizabeth BijouTIME COMPLETED:
02:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPA) Ashley Smith arrived unannounced to conduct a one year required annual. The LPA met with Administrator Elizabeth Bijou and explained the reason for the visit. The five (5) clients were at day program at the time of the visit.

The LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Kitchen: The kitchen area was observed at 9:00 a.m. The facility has a sufficient supply of non-perishable and perishable food items. Cleaning supplies and disinfectants are stored inaccessible to clients. Knives are stored in a locked cabinet.

Restrooms: The restrooms were clean and sanitary and in operating condition. The bathrooms were sufficiently stocked with soap and paper towels. At 9:30 a.m., the hot water temperature measured in the hallway restroom at 113.7 degrees Fahrenheit.

Bedrooms: The LPA toured the client rooms. There are three (3) shared client rooms, which were furnished with appropriate linens and required furniture. A linen closet was located outside of the rooms, which stocked extra linens and towels.

Common areas: Living and dining room furniture were observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. Smoke and carbon monoxide detectors were tested at 9:20 a.m. and operational at the time of the visit. The LPA observed required postings throughout the common space. The fire extinguisher was charged but there was no proof of purchase or service.

The backyard has a covered outdoor area equipped with outdoor furniture. The side gate was self-closing and latched. No bodies of water noted. The garage is detached and pad-locked, inaccessible to clients.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: AMIGO HOME II
FACILITY NUMBER: 197603491
VISIT DATE: 07/07/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Records: The LPA reviewed client and staff records at 10:00 a.m. The LPA reviewed five (5) client files for, but not limited to, the following: admission agreements, medical assessments with TB results, consent forms, and current needs and services plan. Out of the five (5) files reviewed, all files require an updated Needs & Services Plan. Two out of five clients (C1, C2) need a signed admission’s agreement. One out of five clients (C1) needs a completed medical assessment. The Administrator's Certificate expires 9/25/2024.

The LPA reviewed staff files for, but not limited to: personnel records, health screening, criminal record statements, first aid certification. Files were complete. Disaster drills are regularly conducted, the last one conducted on 7/1/2023.

Medications: Medications review began at 11:50 a.m.; medications are centrally stored and locked in a cabinet in the hallway; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. The LPA advised the Administrator to ensure that all the necessary information is properly documented on the centrally stored medications and destruction record if it is being completed by the pharmacy. No errors observed during the medication review.

The LPA obtained the following documents:


- Infection Control Plan
- Emergency Disaster Plan

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/07/2023 02:01 PM - It Cannot Be Edited


Created By: Ashley Smith On 07/07/2023 at 12:42 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
,
, CA

FACILITY NAME: AMIGO HOME II
FACILITY NUMBER: 197603491

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 1 fire extinguishers, which poses a potential health and safety risk to persons in care
POC Due Date: 07/21/2023
Plan of Correction
1
2
3
4
The Administrator agreed to do the following:
1. Purchase a new fire extinguisher or have it serviced. Submit proof to CCL by 7/21/2023
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 out of 5 files (C1, C2) which poses a potential health and safety risk to persons in care.
POC Due Date: 07/21/2023
Plan of Correction
1
2
3
4
The Administrator agreed to do the following:
1. Obtain signed admissions agreements for C1 and C2. Submit proof to CCL by 7/21/2023
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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Ashley Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/07/2023 02:01 PM - It Cannot Be Edited


Created By: Ashley Smith On 07/07/2023 at 12:42 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
,
, CA

FACILITY NAME: AMIGO HOME II
FACILITY NUMBER: 197603491

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068.3(a)
Modifications to Needs and Services Plan
(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy, but at least annually. These modifications shall be maintained in the client's file.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 5 out of 5 files (C1, C2, C3, C4, C5) which poses a potential health and safety risk to persons in care
POC Due Date: 07/21/2023
Plan of Correction
1
2
3
4
The Administrator agreed to do the following:
1. Complete the needs and services plan for all five clients. Submit proof to CCL by 7/21/2023
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 5 client files (C1) which poses a potential health and safety risk to persons in care
POC Due Date: 07/21/2023
Plan of Correction
1
2
3
4
The Administrator agreed to do the following:
1. Obtain a completed physician's report for C1. Submit proof to CCL by 7/21/2023
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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Ashley Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023


LIC809 (FAS) - (06/04)
Page: 4 of 4