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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606734
Report Date: 11/22/2021
Date Signed: 11/22/2021 01:32:28 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
11/15/2021 and conducted by Evaluator Melissa Ruiz
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20211115165316
FACILITY NAME:O-2 HOUSEFACILITY NUMBER:
197606734
ADMINISTRATOR:CLIFTON VON BUCKFACILITY TYPE:
735
ADDRESS:43956 21ST STREET WESTTELEPHONE:
(661) 729-1000
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:4CENSUS: 4DATE:
11/22/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:William Tan - StaffTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Licensee yells at residents.
INVESTIGATION FINDINGS:
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At 10:30 a.m., Licensing Program Analyst (LPA) Melissa Ruiz made an unannounced visit to conduct a complaint investigation for the allegation mentioned above. Upon arrival, LPA was greeted by staff 1 (S1), and spoke with the licensee over the phone. The purpose of this visit was explained, and licensee arrived at the facility later that day.

To investigate the complaint, LPA conducted interviews with three out of four residents, one staff member, one witness (witness 1) and the licensee from 10:40-11:30 a.m. A telephonic interview was conducted with licensee, and licensee stated he does not yell at residents but does points to an argument that occurred a week ago between licensee and two residents that could be related to this allegation. An interview with S1 revealed they believe licensee has a “normal tone” but can’t say how others may perceive his tone.

(cont. on 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
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-20211115165316
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: O-2 HOUSE
FACILITY NUMBER: 197606734
VISIT DATE: 11/22/2021
NARRATIVE
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Interviews with R1 and R2 revealed that they have experienced licensee raise their tone towards them various times. Witness 1 stated they have heard the licensee yell at R1 while being on the phone with R1.

R3 has stated they have not experienced the licensee yell at them but has heard licensee raise their tone att R1, specifically an incident that occurred about a week ago.

Based on today’s findings, this allegation is deemed substantiated. Report delivered. Exit interview conducted. Appeal rights issued and deficiencies cited, see 9099-D page.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20211115165316
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: O-2 HOUSE
FACILITY NUMBER: 197606734
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/01/2021
Section Cited
CCR
80072(a)(1)
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80072 (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons.
This requirement is not met as evidenced by:
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The licensee will particiate in personal rights training conducted by an outside vendor. Proof of scheduled training will be submited to LPA by the POC due date 12/01/21.
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Based on interviews conducted, 3 out of 4 residents have experienced or witnessed licensee yell or raise tone to residents which poses a potential Personal Rights risk to persons 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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3