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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608194
Report Date: 04/19/2022
Date Signed: 04/19/2022 02:18:50 PM

Document Has Been Signed on 04/19/2022 02:18 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 CARE, INC.FACILITY NUMBER:
197608194
ADMINISTRATOR:UGORJI ONYIKEFACILITY TYPE:
735
ADDRESS:7438 AMIGO AVETELEPHONE:
(818) 881-6848
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 4CENSUS: 4DATE:
04/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Ugorji OnyikeTIME COMPLETED:
02:25 PM
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At approximately 12:45 p.m. on 04/19/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. 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 05/09/2012 for an annual inspection visit. It is a single story building with 3 bedrooms, 1 bathroom, a staff room, kitchen, living room, dining room, garage, and outdoor areas. It has an approved fire clearance for 4 ambulatory residents.

Entry: LPA observed a table outside of the front door with hand sanitizer and sanitizing wipes. Signs for the facility’s masking requirement were posted on the front door. Once inside, LPA observed postings for COVID precautions, house rules, personal rights, grievance procedure, emergency contacts, confidential complaints, and the latest Provider Information Notice (PIN).

Screening: LPA was screened for symptoms of COVID-19 upon entry. Administrator showed visitor log and screening documents. Temperature, symptoms, and proof of vaccination were all documented. At 1:47 p.m. staff screened consumer returning from day program.

Bedrooms: The facility has 3 bedrooms. 2 are private bedrooms and 1 is shared. All bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition. Beds in the shared bedroom were at least 6 feet apart.

Bathrooms: The facility has 1 bathroom. It contained liquid soap, paper towels, a handwashing instruction sign, a trash can with a lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 1:30 p.m. LPA measured the water temperature in the bathroom to be 110.4 degrees Fahrenheit.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: AMIGO HOME CARE, INC.
FACILITY NUMBER: 197608194
VISIT DATE: 04/19/2022
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Kitchen: LPA observed an adequate supply of perishable and non-perishable food. The vent above the stove was clean. Surfaces were sanitary. LPA observed a complete first aid kit hung on the kitchen wall. The house phone was located in the kitchen as well. Facility files and consumer medication were locked near the dining room. Activity schedule and weekly menu were posted,

Common Areas: Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. At 2:00 p.m. LPA measured the room temperature to be 77.4 degrees Fahrenheit.

Garage: The garage was locked and contained a washer, dryer, and extra PPE supplies. Machines were in good condition. Detergent was locked above the appliances.

Safety: All emergency exit paths were free from obstructions. 2 out of 2 exit gates were unlocked with inward facing latches. Emergency Disaster Plan was posted at the front. Exit routes were clearly labeled. At approximately 1:35 p.m. LPA tested the smoke detector and carbon monoxide detector to be operational. At approximately 1:40 p.m. LPA observed a fully charged fire extinguisher in the kitchen.

Outdoor areas: LPA observed a covered patio, gas grill, and basketball hoop outside. All areas were clean and free from debris.

During today's inspection, the facility is in compliance with Title 22 regulations.

Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
LIC809 (FAS) - (06/04)
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