197606734-3-22-2024-31-AS-MVAO-D42P6Y-20240405110306

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606734
Report Date: 03/22/2024
Date Signed: 03/22/2024 03:14:44 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
03/15/2024 and conducted by Evaluator Evelin Rios

COMPLAINT CONTROL NUMBER: 31-AS-20240315103445

FACILITY NAME:	O-2 HOUSE		FACILITY NUMBER:	197606734
ADMINISTRATOR:	CLIFTON VON BUCK		FACILITY TYPE:	735
ADDRESS:	43956 21ST STREET WEST		TELEPHONE:	(661) 729-1000
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	4	CENSUS: 4	DATE:	03/22/2024
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Cifton VonBuck		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not providing a safe environment for resident.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

At 12:15 p.m., Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced complaint investigation at the above facility to investigate the allegation mentioned. LPA met with Staff #1 (S1), who granted access to the facility. Staff #2 (S2) contacted administrator and LPA explained the purpose of the visit to the administrator. LPA conducted an entrance interview with administrator. Administrator met LPA shortly after.

At 12:30 p.m. LPA toured the physical plant and conducted interviews with two (2) staff members. At approximately 1:00 p.m. LPA interviewed client #1 (C1). LPA also requested and reviewed copies of pertinent information which include, C1's Physician’s Report, C1's Pre Admission Appraisal, Special Incident Reports (SIRs) involving C1, and C1's Individual Program Plan (IPP). At 2:15 p.m. LPA conducted an interview with client #2 (C2). Regarding the allegation, staff are not providing a safe environment for resident. It is alleged client #1 (C1) is being hurt by others.
(Continue on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024

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 2

Control Number 31-AS-20240315103445

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: 03/22/2024

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

(Continued from LIC9099)

To investigate the allegation LPA conducted interviews with two (2) staff present during the incident in question, the administrator and two (2) out of four (4) clients. LPA reviewed pertinent documents regarding the allegation. Interview with C1 revealed they had a relationship with the accused perpetrator not related to this facility. According to C1, they had willingly left the facility acknowledging that they should have signed out but didn't, and later while making their way back to the facility the accused perpetrator struck C1. C1 made it to the facility and informed staff about the incident. Staff contacted 911. Paramedics checked C1's vitals and Lancaster Sheriffs took a report. Staff called administrator and administrator had staff contact 911 to have C1 transported to the hospital. Administrator submitted incident report that included Lancaster Sheriffs report number to Community Care Licensing (CCL), and North Los Angeles County Regional Center. Administrator also filed a report with Adult Protective Services (APS). Furthermore, C1 informed LPA they feel safe at the facility and that nobody in the facility has hurt them. Based on record review and interviews conducted the allegation, staff are not providing a safe environment for resident, is deemed Unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2