197608194-1-5-2023-31-AS-NRED-CMSUMX-20230105144305

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608194
Report Date: 01/05/2023
Date Signed: 01/05/2023 02:43:12 PM

Document Has Been Signed on 01/05/2023 02:43 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 ONYIKE		FACILITY TYPE:	735
ADDRESS:	7438 AMIGO AVE		TELEPHONE:	(818) 881-6848
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY: 4		CENSUS: 5	DATE:	01/05/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Victor Onyike		TIME COMPLETED:	03:00 PM

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At 2:20 p.m. on 01/05/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with staff and disclosed the reason for the visit.

Today’s case management visit was conducted in response to 2 incident reports submitted by the facility. The facility properly reported incidents of AWOLs on 12/11/2022 and 01/01/2023 of Client #1 (C1). In both incidents, facility staff followed protocol listed in the facility’s plan of operations. Emergency services were notified, and all applicable parties were notified.

At 2:30 p.m. today, LPA conducted a record review of C1’s files. C1’s medical assessment showed they are able to leave the facility unassisted. At 2:35 p.m. LPA interviewed Staff #1 (S1). To prevent further elopements, S1 reminded C1 to communicate with staff when C1 is leaving and when C1 would return. S1 stated C1 may have an upcoming meeting with the Regional Center to address the behaviors.

During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued.

Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2023

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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