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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015202110
Report Date: 05/09/2024
Date Signed: 05/09/2024 04:36:11 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
01/25/2024 and conducted by Evaluator Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240125151254
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: 5DATE:
05/09/2024
UNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Yolanda EsterasTIME COMPLETED:
04:50 PM
ALLEGATION(S):
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Staff do not have current physician orders for a client
Staff are administering unauthorized medication to a client
Staff are allowing unauthorized treatments for a client
Staff did not timely meet a client's medical needs
INVESTIGATION FINDINGS:
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On this day at around 2:25pm, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to deliver finding for the above allegations and met with House Manager Yolanda Esteras . LPA explained to Esteras the purpose of the visit.

During the course of investigation, LPA conducted 10-day investigation, obtained and reviewed records and interviewed staff.

Allegation: Staff did not meet a client's medical needs in timely manner.

For Client 2 (C2), there are lab works ordered by C2’s doctor that were not completed. Also, it was noted that C2’s assessment does not include information regarding C2’s diagnosis of Congestive Heart Failure.

continuation on Lic 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
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 4
Control Number 15-AS-20240125151254
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: 05/09/2024
NARRATIVE
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Allegations:

Staff are providing treatments for a client without doctor's order

Staff are administering medications without doctor's order

Staff do not have current physician orders for a client

Based on interviews and record reviews conducted, the facility has been providing treatments such Tei Fu, Peppermint, Aloe vera and over the counter (OTC) medications such as tea tree oil, beeswax, unlabeled cream, etc to C1 without signed doctor’s order since August 18, 2023.

Based on record reviews and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22, are being cited on the attached LIC 9099D.



Exit interview was conducted with Esteras and Appeal Rights was provided
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20240125151254
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: 05/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/23/2024
Section Cited
CCR
80075(b)(6)(D)
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80075(b)(6)(D) Health Related Services
(D) For every prescription and nonprescription PRN medication for which the licensee provides assistance, there shall be a signed, dated written order from a physician on a prescription blank, maintained in the client's file, …


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The facility will obtain doctor's orders for all OTC medications and treatments and submit proof to CCL by POC date.
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This requirement is not met as evidenced by: Based on interviews and record reviews conducted, C2 is being given the following medications without a written doctor’s order:

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Type B
05/23/2024
Section Cited
CCR
80075(a)
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80075(a) Health Related Services
a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services.
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The Administrator will review all clients' medical and dental services needed and submit self-certification stating completion of all needed services.
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This requirement is not met as evidenced by: Based on records review conducted, C2 had lab works ordered by the doctor that were not completed which poses a potential risk to the health and safety of clients under 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: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20240125151254
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: 05/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2024
Section Cited
CCR
80068.3(a)
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80068.3(a) Modifications to Needs and Services Plan
(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy, but at least annually. These modifications shall be maintained in the client's file.
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The Administrator will update C2's assessment and submit a copy to CCL by POC date.
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This requirement is not met as evidenced by: Based on record review conducted, C2’s assessment did not include information regarding C2’s diagnosis of Congestive Heart Failure which poses a potential risk to the health and safety of clients under 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: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4