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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200593
Report Date: 09/16/2025
Date Signed: 09/16/2025 12:39:26 PM

Unsubstantiated


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
09/11/2025 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20250911100252
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: 4DATE:
09/16/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Bricia CastroTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff did not allow client in care to go on outings
Staff restricted client's ability to use the facility common areas
INVESTIGATION FINDINGS:
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 On 09/16/2025 at 9:00AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to conduct a complaint visit. LPA explained the purpose of the visit with staff Bricia Castro.

During the initial 10-day complaint visit, LPA interviewed staff, and witnesses.

On the allegation of: Staff did not allow client in care to go on outings
S1 stated that the outing was pre planned when R1 was in the hospital. R1 returned from the hospital before the outing had occurred, but was not able to join on the outing due to the vehicale only having room for three wheelchairs which were already being used by the other three residents. S1 offered R1 alternitives included an individual outing on a diffrent day but R1 declined.

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

DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025
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 2
Control Number 15-AS-20250911100252
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: 09/16/2025
NARRATIVE
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...Continued from LIC 9099

On the allegations of: Staff restricted client's ability to use the facility common areas
When R1 returned from the hospital the doctor gave discharge instructions of contact precautions after having a Multi Drug Resistant Organism (MDRO) bacteria in a wound. W1 stated that staff were confused and asked R1 when they were in a common area to maintain 6-feet of distance from staff and other residents. R1 was never asked not to be in or use the common area.

Although the allegations may have happened or are valid, there are 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 this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2