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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320109
Report Date: 08/18/2023
Date Signed: 02/28/2024 01:37:45 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/26/2023 and conducted by Evaluator Perry Scott
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230726093700
FACILITY NAME:AMBER ADULT RESIDENTIAL HOMEFACILITY NUMBER:
198320109
ADMINISTRATOR:CYRIL-EZIWHOU, CHIMENEM MFACILITY TYPE:
735
ADDRESS:19315 WEISER AVENUETELEPHONE:
(415) 374-0060
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY:4CENSUS: 4DATE:
08/18/2023
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Olushola AinaTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Client sustained multiple unexplained injuries while in care.
Facility staff handles resident in a rough/inappropriate manner.
Facility staff speaks in an inappropriate manner to client in care.
INVESTIGATION FINDINGS:
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On 08/02/23, Licensing Program Analyst (LPA), Perry Scott initiated a 10-day complaint investigation at the facility listed above. LPA Scott met with Chimenem Cyril-Eziwhou, Administrator, and explained the purpose of today’s visit was to investigate the allegations listed above.

On 08/02/23, the investigation consisted of the following:

During today's visit LPA conducted interviews with the staff (S1- S3), witnesses (W1-W2). LPA could not interview residents (R1-R4) due to intellectual disabilities. LPA requested and obtained copies of the following documents: Resident and staff roster, Id/Emergency Information, physicians report, discharge hospital summary, face sheets, SIR, Video footage, and Individual Service Plan for residents (R1-R4).

The investigation revealed the following: Regarding allegation #1: Client sustained multiple unexplained injuries while in care.

Report conitinued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024
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 11-AS-20230726093700
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: AMBER ADULT RESIDENTIAL HOME
FACILITY NUMBER: 198320109
VISIT DATE: 08/18/2023
NARRATIVE
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On 08/02/23, LPA interviewed S1-S3 and W1-W2. 3 of 3 staff denied the allegation that Client sustained multiple unexplained injuries while in care. All staff confirmed that R1 had two falls, which were accidents, where R1 lost R1’s balance. R1-R4 could not be interviewed due to cognitive difficulties. 2 of 2 witnesses denied the allegation that Client sustained multiple unexplained injuries while in care. W1 stated that W1 did not have any concerns over the care being provided and believed that the falls were an accident. Service Coordinator for South Central Los Angeles Regional Center W2 stated that the facility requested a one on one for the R1 and was in the process of developing a fall plan for the resident.

Based on interviews and records reviewed there is insufficient evidence to support the allegation: Client sustained multiple unexplained injuries while in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Allegation #2: Facility staff handles resident in a rough/inappropriate manner.

On 08/02/23, LPA interviewed S1-S3 and W1-W2. 3 of 3 staff denied the allegation that Facility staff handles resident in a rough/inappropriate manner. All staff state that no one handles residents roughly or in an inappropriate manner. 2 of 2 witnesses (W1-W2) also denied the allegation and stated they had no knowledge of mistreatment from the facility. R1-R4 could not be interviewed due to cognitive difficulties.

Based on interviews there is insufficient evidence to support the allegation: Facility staff handles resident in a rough/inappropriate manner. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Allegation #3: Facility staff speaks in an inappropriate manner to client in care.

On 08/02/23, LPA interviewed S1-S3 and W1-W2. 3 of 3 staff denied the allegation that Facility staff speaks in an inappropriate manner to client in care. All staff state that no one speaks to the residents in an inappropriate manner. 2 of 2 witnesses also denied the allegation and stated they have no knowledge of mistreatment from the facility. R1-R4 could not be interviewed due to cognitive difficulties.

Based on interviews there is insufficient evidence to support the allegation Facility staff speaks in an inappropriate manner to client in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

No deficiencies were cited.

An exit interview was conducted, and a hard copy of this report was provided to Chimenem Cyril-Eziwhou, Administrator.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024
LIC9099 (FAS) - (06/04)
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