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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606734
Report Date: 11/08/2023
Date Signed: 11/08/2023 03:58:18 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
05/23/2023 and conducted by Evaluator Evelin Rios
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20230523085135
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:
11/08/2023
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Clifton VonBuckTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff intimidated resident in care.
INVESTIGATION FINDINGS:
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On 11/08/2023 Licensing Program Analyst, (LPA) Evelin Rios conducted a subsequent unannounced visit and was greeted by staff#1 (S1). LPA stated the purpose of the visit. S1 telephoned the administrator Clifton VonBuck and informed him LPA was at the facility. Administrator met LPA shortly after.

LPA Rios and S1 conducted a tour of the facility. LPA did not observe any health and safety issues.
In conjunction to this complaint LPA conducted a required annual inspection and interviewed staff and client present at the facility during that time. At approximately 1:30 p.m. LPA interviewed the administrator and other clients who arrived at the facility.

Allegation: Staff intimidates resident in care. To investigate the allegation LPA conducted interviews with three (3) out four (4) clients who were present at the facility. LPA interviewed administrator and S1. It is alleged the administrator yelled and forced client#1 (C1) to the social security office.
(Cont. on LIC9099-C)
Unsubstantiated
Estimated Days of Completion: 45-90
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023
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-20230523085135
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: O-2 HOUSE
FACILITY NUMBER: 197606734
VISIT DATE: 11/08/2023
NARRATIVE
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(Continued from LIC9099)
Client interviews denied being yelled at or feeling intimated by the administrator. Client interviews revealed witnessing C1 yell at the Administrator. Administrator and staff denied the allegation and corroborated clients statements about C1 "screaming" or yelling at other clients and staff. According to administrator and staff interviews, present on the day in question C1 went with administrator willingly to the Social Security office. C1 was not in the facility during todays visit. LPA reviewed records stating C1's choice to move out on 06/21/23.

Based on client and staff interviews there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

No decencies cited. Exit interview conducted, and report was signed and delivered.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3