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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015202110
Report Date: 05/19/2023
Date Signed: 05/19/2023 01:48:04 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/04/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220504144640
FACILITY NAME:ELWYN NC - MEADOWLARKFACILITY NUMBER:
015202110
ADMINISTRATOR:MARIO P. RODRIGUEZFACILITY TYPE:
734
ADDRESS:8101 MEADOWLARK CTTELEPHONE:
(510) 797-7940
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY:5CENSUS: 4DATE:
05/19/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Mario Rodriguez, AdministratorTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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5
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7
8
9
Lack of communication between administrator and family
INVESTIGATION FINDINGS:
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2
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5
6
7
8
9
10
11
12
13
On 05/19/23 at 12PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator to deliver the findings of above allegations. LPA explained the purpose of the visit with administrator.

Allegation: Lack of communication between administrator and family
Investigation Finding: Substantiated
During investigation, administrator (ADM) confirmed with LPA that he did not return client’s (C1) authorized representative’s (POA) multiple phone calls on 4/24/22 thru 4/26/22. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) was found to be substantiated. Continued on next page,LIC 9099-C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
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 5
Control Number 15-AS-20220504144640
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ELWYN NC - MEADOWLARK
FACILITY NUMBER: 015202110
VISIT DATE: 05/19/2023
NARRATIVE
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Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D.

Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20220504144640
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ELWYN NC - MEADOWLARK
FACILITY NUMBER: 015202110
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/09/2023
Section Cited
CCR
80065(a)
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7
Facility personnel shall be competent to provide the services necessary to meet individual client needs…

This requirement was not met as evidenced by:
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7
By POC due date, Administrator agrees to submit to CCL completed staff in-service retraining on timely communication with clients and their authorized representatives in compliance with Title 22 Section 80065(a)
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Staff failed to timely communicate in response to C1's POA phone calls which posed a potential safety & health risk to client in care
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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: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/04/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220504144640

FACILITY NAME:ELWYN NC - MEADOWLARKFACILITY NUMBER:
015202110
ADMINISTRATOR:MARIO P. RODRIGUEZFACILITY TYPE:
734
ADDRESS:8101 MEADOWLARK CTTELEPHONE:
(510) 797-7940
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY:5CENSUS: 4DATE:
05/19/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Mario Rodriguez, AdministratorTIME COMPLETED:
01:40 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Neglect/Lack of supervision
Lack of staff training
Unknown scratches on client’s body
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 05/19/23 at 12PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator to deliver the findings of above allegations. LPA explained the purpose of the visit with administrator.

Allegation: Neglect/Lack of supervision
Investigation Finding: Unsubstantiated
During investigation, Witness (W1) confirmed with LPA that staff are licensed medical professionals (CNAs, RNs) trained in providing care to clients in care. LPA observed staff provide proper care & supervision to each client during visit.

Continued on next page, LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20220504144640
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ELWYN NC - MEADOWLARK
FACILITY NUMBER: 015202110
VISIT DATE: 05/19/2023
NARRATIVE
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3
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Allegation: Neglect/Lack of supervision
Investigation Finding: Unsubstantiated
Continuation:
Review of clients’ (C1, C2, C3, C4, C5) Quarterly/Individual Health Care Plans (IHCPs) reports show staff documented and implemented each clients’ health care plans as prescribed and overseen by Regional Center of the East Bay (RCEB) Case Managers and Department of Developmental Services (DDS) Nurse. Semi-annual assessments and meetings were also held with staff, authorized representative (POA), RCEB CM / QA, physicians to ensure C1's individual Service Plan (ISP) & individual Program Plans (IPP) goals for each client are met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation of neglect/lack of supervision is unsubstantiated.

Allegation: Lack of staff training
Investigation Finding: Unsubstantiated
Based on interviews and record reviews which were conducted, staff completed required Direct Service Professional (DSP) on the job trainings prior to working with clients. Witness (W1) confirmed with LPA that staff are licensed skilled professionals (CNAs, RNs) providing proper care and supervision to clients at the facility. W1 stated C1’s POA is very involved with his care to the point that she is telling staff on how to care for C1. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation of lack of staff training is unsubstantiated.

Allegation: Unknown scratches on client’s body


Investigation Finding: Unsubstantiated
During investigation, LPA confirmed with staff (ADM, S8) and witness (W1) that they do not recall seeing scratches on client’s (C1) body. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation of unknown scratches on client’s body is unsubstantiated.
Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5