<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320109
Report Date: 10/02/2025
Date Signed: 10/02/2025 01:02:06 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/24/2025 and conducted by Evaluator Perry Scott
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250924101933
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:
10/02/2025
UNANNOUNCEDTIME BEGAN:
09:21 AM
MET WITH:Chimenem Cyril-EziwhouTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not provide adequate supervision, resulting in a resident wandering away from the facility.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/2/25, at 9:21am, Licensing Program Analyst (LPA) Perry Scott conducted an initial complaint visit to the facility and was greeted by Chimenem Cyril-Eziwhou, Administrator. LPA explained the purpose of this visit was to gather information about the complaint, gather facility files, interview staff, and deliver findings for the allegation mentioned above.

The investigation consisted of the following: The department investigated the allegations mentioned in this complaint and conducted interviews with staff (S1-S3). The department received the following facility documents: Client Roster (Date: 9/06/2025) and Staff Roster (Dated: 02/01/2025), Physician Report (Dated: 01/20/2025), ID/Emergency Information (Dated: 01/02/2025), Admissions Agreement (Dated: 11/14/2022), Resident Profile (Dated: 02/07/2023),South-Central Regional Center Incident report (Dated: 9/22/2025), and South-Central Regional Center Individual Program Plan (IPP) (Dated: 09/24/2024) from the facility.

Report Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025
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 11-AS-20250924101933
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: AMBER ADULT RESIDENTIAL HOME
FACILITY NUMBER: 198320109
VISIT DATE: 10/02/2025
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
The investigation revealed the following: Allegation-Staff did not provide adequate supervision, resulting in a resident wandering away from the facility.

The details of the complaint alleged that the facility did not provide adequate supervision of client resulting in the client wandering away from the facility and ending up in an emergency room. On 10/2/25, from 9:30am-2:00pm, the department interviewed staff (S1-S3) regarding the allegation. 3 of 3 staff (S1-S3) corroborated that client (C1) did wander away from the facility on 09/22/2025. Staff (S1) stated that on 9/22/25, their staff member (S3) was helping another client get ready for the day and assisting them with personal care. When the staff (S3) went to check on C1 to get them ready for the day program, they could not find C1. Staff called 911 and South-Central Regional Center and reported that the client went awol from the facility. Staff (S3) corroborated this account and stated that the client ended up at Martin Luther King hospital where they picked them up later that day and returned them to the facility unharmed with no bruises.

The department reviewed the South-Central Regional Center Incident report during the department’s complaint investigation on 10/2/2025 and observed that a report was filed. However, the facility failed to notify Community Care Licensing Division about the incident within seven days, which Title 22 regulations require.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation Staff did not provide adequate supervision, resulting in a resident wandering away from the facility, is found to be Substantiated. California Code of Regulations, Title 22, Division (6) and chapter (1) and (2) are cited on the attached LIC 9099D.

Note: *Citations that are not cleared by the due date of 10/10/25 will have a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. Deficiency was cleared at the time of the visit.

Deficiencies were issued and plans of corrections were discussed.

An exit interview was conducted with Chimenem Cyril-Eziwhou, Administrator, and a hard copy of this Complaint Investigation Report was provided.

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

DATE: 10/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20250924101933
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: AMBER ADULT RESIDENTIAL HOME
FACILITY NUMBER: 198320109
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/10/2025
Section Cited
CCR
80078(a)
1
2
3
4
5
6
7
80078 (a) Responsibility for Providing Care and Supervision: The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
The administrator will read Title 22 Regulations 80078 (a) Responsibility for Providing Care and Supervision, and provide in-service training to all staff, and provide proof of training to CCLD by POC date of 10/10/25 to LPA Perry Scott email perry.scott@dss.ca.gov to avoid monetary penalties.
8
9
10
11
12
13
14
Based on record reviews and interviews conducted the administrator failed to provide proper supervision for client (C1). On 9/22/25, client was left unattended and wandered away from the facility and ended up in the emergency room, which poses a potential health and safety risk to clients in care.
8
9
10
11
12
13
14
Type B
10/10/2025
Section Cited
CCR
80061(b)(1)(E)
1
2
3
4
5
6
7
80061(b)(1)(E) Reporting Requirements Upon the occurrence...a report shall be made...next working day during its normal business hours. In addition, a written report ...within seven days ...event. Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Administrator will provide CCLD with an SIR of the incident that occurred on 09/22/25. The administrator will also read Title 22 Regulations 80061(b)(1)(E) Reporting Requirements, and provide in-service training to all staff, and provide proof of training to CCLD by POC date of 10/10/25 to LPA Perry Scott email perry.scott@dss.ca.gov to avoid monetary penalties.
8
9
10
11
12
13
14
Based on record reviews and interviews conducted the administrator failed to report an unusual incident which threatens the physical or emotional health or safety of any client, a report was not submitted to CCLD regarding a client (C1) leaving the facility and ending up in an emergency room on 9/22/25; which poses a potential health and safety risk to clients in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3