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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200593
Report Date: 01/31/2025
Date Signed: 01/31/2025 12:08:22 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
01/28/2025 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20250128102128
FACILITY NAME:ELWYN CALIFORNIA - KEITHFACILITY NUMBER:
079200593
ADMINISTRATOR:VIERNES, ADRIANFACILITY TYPE:
734
ADDRESS:1141 KEITH DRTELEPHONE:
(408) 558-1500
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:4CENSUS: 3DATE:
01/31/2025
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Ritchie Villapando, Interim Administrator TIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff spoke inappropriately towards a client while in care
Staff yelled at a client while in care
INVESTIGATION FINDINGS:
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On 01/31/2025 at 9:30AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to conduct a complaint visit. LPA explained the purpose of the visit with LVN Mylene Arthurs and explained the purpose of the visit. Regional Director Chris Park was called and informed of the visit. Interim Administrator Ritchie Villapando joined later.

On the allegation: Staff yelled at a client while in care, LPA confirmed thorugh incident reports and interviews that S3, yelled at C1 while C1 was at the facility.

On the allegation:Staff spoke inappropriately towards a client while in care, LPA confirmed thorugh incident reports and interviews that S3 said "Shut up" to C1, while at the facility.

Continued on 9099-C....
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025
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 15-AS-20250128102128
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 CALIFORNIA - KEITH
FACILITY NUMBER: 079200593
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2025
Section Cited
CCR
80072(a)(1)
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80072 Personal Rights (a) ... each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons.
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Licensee to do in-service training for ALL STAFF MEMBERS and send to Community Care Licensing copy of training topic with attendees signatures by 2/10/2025.
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This requirement was not met as evidenced by:
Staff Member S3 yelling at all of the Clients in the facility.
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Type B
02/10/2025
Section Cited
CCR
80072(a)(3)
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 (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion,... interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning
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Licensee to do in-service training for ALL STAFF MEMBERS and send to Community Care Licensing copy of training topic with attendees signatures by 2/10/2025.
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This requirement was not met as evidenced by:
Staff Member S3 said Shut Up to Client C1.
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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: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20250128102128
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 CALIFORNIA - KEITH
FACILITY NUMBER: 079200593
VISIT DATE: 01/31/2025
NARRATIVE
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...Continued from 9099

The preponderance of the evidence standard has been met, and the allegation is SUBSTANTIATED.


Deficiency is cited under the California Health and Safety Code listed on LIC9099-D. 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: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3