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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015202110
Report Date: 06/25/2025
Date Signed: 06/25/2025 04:34:53 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
08/26/2022 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20220826164708
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:
06/25/2025
UNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Julie Ann Caparino/Administrator-in-TrainingTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Facility was not allowing indoor visitation.
INVESTIGATION FINDINGS:
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On this day, June 25, 2025, at 3:10 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegation. LPA was granted entry by Hazel Armat, staff/RN, and informed the reason for visit. Julie Ann Caparino, administrator-in-training, arrived at 3:21 pm. LPA called and left message on Ruby Abalos-Velario's (administrator) voicemail. LPA also spoke over the phone with Regional Director Chris Park.

During the course of investigation, LPA reviewed resident files. LPA conducted inspection and interviewed the following staff (S1, S2, S3, S4 and previous administrator (PADM)) on 9/01/22. LPA also interviewed one of the resident’s family member (FM) on 8/30/22.


......continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2025
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 5
Control Number 15-AS-20220826164708
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: 06/25/2025
NARRATIVE
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FM stated the facility was not allowing indoor visitation. All staff interviewed including PADM stated the facility does not allow indoor visitation when facility has positive case of COVID-19 per directive from facility’s administration; however, at the time the complaint was received, a Provider Information Notice had been released by the Department allowing indoor visitation. During investigation on 9/01/22, LPA observed one the staff brought the resident in the backyard when this resident’s family member came to visit. Therefore, the allegation is substantiated.

Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of correction by plan of correction due date may result in civil penalty.

Deficiency and plan and proof of correction were discussed over the phone with Chris Park in the presence of Julie Ann Caparino.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20220826164708
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: 06/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/09/2025
Section Cited
CCR
85072(b)(4)
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85072 Personal Rights
(b) The licensee shall insure that each client is accorded the following personal rights. (4) To have visitors, including advocacy representatives, visit privately during waking hours, provided that such visitations do not infringe upon the rights of other clients.
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Regional Director agreed to in-service the staff. Copy of the training topic with attendees signatures to be submitted by 7/09/25.
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-This requirement is not met by evidenced by:
-Based on observation and interviews, the licensee did not comply with the section above in not allowing indoor visitation which posed a potential rights risks to persons 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: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2025
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
08/26/2022 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20220826164708

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:
06/25/2025
UNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Julie Ann Caparino/Administrator-in-TrainingTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Staff are not taking precautions for COVID-19.
INVESTIGATION FINDINGS:
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On this day, June 25, 2025, at 3:10 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegation. LPA was granted entry by Hazel Armat, staff/RN, and informed the reason for visit. Julie Ann Caparino, administrator-in-training, arrived at 3:21 pm. LPA called and left message on Ruby Abalos' (administrator) voicemail. LPA also spoke over the phone with Regional Director Chris Park.

During the course of investigation, LPA reviewed resident files. LPA conducted inspection and interviewed the following staff (S1, S2, S3, S4 and previous administrator (PADM)) on 9/01/22. LPA also interviewed resident’s family member (FM) and other agency’s medical professional (DMF) on 8/30/22.

......continued on 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2025
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-20220826164708
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: 06/25/2025
NARRATIVE
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FM stated that the facility had cases of COVID-19 when other facility didn’t have. FM expressed concern that if the facility staff were not taking precautions, resident (R1) may also get COVID-19 virus.

DMF stated she conducted a visit and didn’t observed anything about facility not adhering to COVID-19 precautions. DMF further stated she had done numerous technical calls with the facility and didn’t observe anything concerning.

All staff interviewed stated the facility perform disinfecting regularly, quarantined those who tested positive and staff wear full PPEs and followed proper donning and doffing off of PPEs. They screened staff and residents daily for symptoms of COVID-19. They were all fit tested for N95 respirators, copies of which were obtained by LPA during investigation. LPA observed the facility conducted screening of visitors and kept record. LPA also observed COVID-19 signage all through out the facility. Due to medical diagnosis, LPA was not able to obtain information from the residents. Therefore, the allegation is unsubstantiated.

No deficiency cited.

Exit interview conducted and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5