015202110-5-20-2026-15-AS-BFOG-DVAVMA-20260622163313

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015202110
Report Date: 05/20/2026
Date Signed: 05/20/2026 12:07:26 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
03/10/2026 and conducted by Evaluator Alona Gomez

COMPLAINT CONTROL NUMBER: 15-AS-20260310120011

FACILITY NAME:	ELWYN NC - MEADOWLARK		FACILITY NUMBER:	015202110
ADMINISTRATOR:	JULIE ANN CAPARINO		FACILITY TYPE:	734
ADDRESS:	8101 MEADOWLARK CT		TELEPHONE:	(510) 797-7940
CITY:	NEWARK	STATE: CA	ZIP CODE:	94560
CAPACITY:	5	CENSUS: 5	DATE:	05/20/2026
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator, Evelyn Andrews		TIME COMPLETED:	12:25 PM

ALLEGATION(S):

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Facility not following reporting requirements

INVESTIGATION FINDINGS:

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At approxiamately 9:30 PM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to deliver investigation findings on the above allegations and met with Administrator, Evelyn Andrews. LPA explained the purpose of the visit.

On the allegation "Facility not following reporting requirements" LPA interviewed previous Administrator and they stated that Client 1 (C1's) responsible party (RP) alleged staff 1 (S1) abused C1 however they did not complete an SOC341 or Special incident report (SIR) a report because they deemed it unsubstantiated.

report continues on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2026

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 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
03/10/2026 and conducted by Evaluator Alona Gomez

COMPLAINT CONTROL NUMBER: 15-AS-20260310120011

FACILITY NAME:	ELWYN NC - MEADOWLARK		FACILITY NUMBER:	015202110
ADMINISTRATOR:	JULIE ANN CAPARINO		FACILITY TYPE:	734
ADDRESS:	8101 MEADOWLARK CT		TELEPHONE:	(510) 797-7940
CITY:	NEWARK	STATE: CA	ZIP CODE:	94560
CAPACITY:	5	CENSUS: 5	DATE:	05/20/2026
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator, Evelyn Andrews		TIME COMPLETED:	12:25 PM

ALLEGATION(S):

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Facility not providing a healthful and comfortable accommodations, furnishings and equipment to meet clients needs.
Staff not providing resident with dignity and respect in interactions
Staff does not follow residents care plan
Staff took residents personal items
Staff physically abuse resident resulting in bruises and cuts
Facility improperly restraining resident

INVESTIGATION FINDINGS:

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At approxiamately 9:30 PM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to deliver investigation findings on the above allegations and met with Administrator, Evelyn Andrews. LPA explained the purpose of the visit.

LPA reviewed C1, C2, and C3: Physician's Orders, Face Sheet, Individual Health Care Plans, Care Plan/appraisasl, 6 months Care Notes/charting, SIR's. LIC 500s, All current staff training, Staff schedules for 2026, and Internal Investigation Summaries. On 3/17/2026 LPA observed C1, C2, and C3. on 5/20/2026 LPA interviewed S2, S3, and S4.

report continues on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 15-AS-20260310120011

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ELWYN NC - MEADOWLARK	FACILITY NUMBER: 015202110
	VISIT DATE: 05/20/2026

NARRATIVE

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On the allegation "Facility not providing a healthful and comfortable accommodations, furnishings and equipment to meet clients needs." LPA observed on 3/17/2026 and todays visit the facility to be clean and free of odors. All furnishings were in good repair and adequate to meet the needs of the clients. LPA did not observe any areas of concern, therefore the allegation is Unsubstantiated.

On the allegation "Staff not providing resident with dignity and respect in interactions" LPA interviewed previous administrator, S2, S3, and S4. Previous Administrator states that there was a concern from C1's RP regarding interactions with S1 however there was not evidence to support that S1 intimidated or disrespected C1. LPA also interviewed the above staff members who all stated that they have not heard any of their colleagues be inappropriate or disrespectful towards clients. While at the facility visits LPA did not observe any concerning behaviors. LPA was unable to interview any clients due to their diagnosis or being away from the facility, therefore the allegation unsubstantiated.

On the allegation "Staff does not follow residents care plan" LPA interviewed previous administrator, S2, S3, and S4. LPA also reviewed care plans for C1, C2, and C3. During interviews all individuals were knowledgeable of clients needs and services and the information provided corresponded with the clients care plans. LPA observed the clients in good health and without distress therefore the allegation is Unsubstantiated.

On the allegation "Staff took residents personal items" LPA conducted interviews and was unable to identify any personal items that were taking. LPA also spoke with the reporting party who was unable to provide any additional information to corroborate the allegation therefore the allegation is Unsubstantiated.

Report continues on LIC 9099-C

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 15-AS-20260310120011

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ELWYN NC - MEADOWLARK	FACILITY NUMBER: 015202110
	VISIT DATE: 05/20/2026

NARRATIVE

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Pg 3.

On the allegation "Staff physically abuse resident resulting in bruises and cuts" LPA conducted interviews and received photos. During all interviews with staff they all stated that C1 gets agitated and leaves superficial cuts on themself. On 3/17/2026 LPA did observe a small cut on C1 that appeared to be self inflicted from fingernails. LPA also obtained photos of C1 with bruising and cuts however LPA was unable to validate when and where the photo was taken. LPA requested additional information from the reporting party to validate that the injuries were sustained while at the facility however no additional information was provided therefore the allegation is Unsubstantiated.

On the allegation "Facility improperly restraining resident" LPA conducted interviews and reviewed care plans/documents. All staff state that C1 previously had mittens utilized as a restraint however they are not used anymore. LPA observed a previous order and the proper documentation for the use of the mittens were available. LPA was unable to identify any improper restraints being used and was unable to obtain any additional information therefore the allegation is Unsubstantiated.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of report provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2026

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 15-AS-20260310120011

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ELWYN NC - MEADOWLARK	FACILITY NUMBER: 015202110
	VISIT DATE: 05/20/2026

NARRATIVE

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Previous Administrator was unable to provide specific dates however they stated that they do remember C1's RP alleging abuse against S1. They felt as if S1 was intimidating C1. However the previous administrator states that there was no proof of the allegation so they did not report it. States that they did an internal investigation. LPA explained that allegations of abuse or intimidation should be reported even if they do not believe it to be true. Therefore the allegation "Facility not following reporting requirements" is Substantiated.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 15-AS-20260310120011

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ELWYN NC - MEADOWLARK	FACILITY NUMBER: 015202110
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/20/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/01/2026 Section Cited CCR 80061(a)	1 2 3 4 5 6 7	(a) Each licensee or applicant shall furnish to the licensing agency reports as required by the Department, including, but not limited to, those specified in this section. This requirement was not met as evidence by:	1 2 3 4 5 6 7	By POC facility agrees to conduct an inservice on reporting requirements with all staff and notify CCLD.
	8 9 10 11 12 13 14	Based on interview with the preivious Administrator it was found that there was an allegation that staff 1 (S1) abused C1 however the Administrator states that they did not complete an SOC341 or Special incident report (SIR) a report because they deemed it unsubstantiated which posed a potential personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2026

LIC9099 (FAS) - (06/04)

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