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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200593
Report Date: 01/29/2026
Date Signed: 01/29/2026 06:28:04 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
10/31/2025 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20251031102903
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:
01/29/2026
UNANNOUNCEDTIME BEGAN:
03:55 PM
MET WITH:Vivian McGill, House ManagerTIME COMPLETED:
06:40 PM
ALLEGATION(S):
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Staff did not ensure that resident's dental needs were met while in care.
INVESTIGATION FINDINGS:
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On 1/29/2026 at 3:55PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegation above. LPA met with House Manager, Vivian McGill and informed her the reason for visit.

During the course of investigation, LPA interviewed 2 staff, 2 witnesses, and complainant. LPA reviewed and obtained documents including Individual Program Plan, Individual Health Care Plan, care notes, dental visits notes, centrally stored medication records, medication administration records (MAR), and emergency information.

After reviewing C1's dental visits notes, C1's dental visit on 11/29/2024 recommended C1 to follow up in 3 months for possible two teeth extractions. However, C1 did not have a dental visit until 4/5/2025 and no indication that facility staff follow up with dental provider regarding possible teeth extractions for C1 until July 2025.
(Continue LIC9099C...)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
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 4
Control Number 15-AS-20251031102903
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: 01/29/2026
NARRATIVE
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C1 had another dental visit on 7/25/2025 with recommendation of 4 teeth extractions. However, C1 end up having 8 teeth extractions.

Interview with witness (W2) indicated the dentist recommended 2 teeth extractions for C1 in November 2024 and facility staff did not follow up with dental provider. W2 stated C1 end up having all 8 teeth extracted and C1 does not have anymore teeth currently.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20251031102903
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: 01/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/30/2026
Section Cited
CCR
80075(a)
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Health Related Services. (a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services...This requirement is not met as evidence by:
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Facility has agreed to create a written plan to address follow ups for client's dental care and include training for staff. Facility will submit written plan to CCLD by POC date.
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Based on interviews and record review, licensee did not comply with the section cited above by not following up with C1's possible 2 teeth extractions and resulted in all 8 teeth extractions which poses an immediate health and safety risk to the 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: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
10/31/2025 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20251031102903

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:
01/29/2026
UNANNOUNCEDTIME BEGAN:
03:55 PM
MET WITH:Vivian McGill, House ManagerTIME COMPLETED:
06:40 PM
ALLEGATION(S):
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2
3
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9
Staff did not update medication records.
INVESTIGATION FINDINGS:
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On 1/29/2026 at 3:55PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegation above. LPA met with House Manager, Vivian McGill and informed her the reason for visit.

During the course of investigation, LPA interviewed 2 staff, 2 witnesses, and complainant. LPA reviewed and obtained documents including Individual Program Plan, Individual Health Care Plan, care notes, dental visits notes, centrally stored medication records, medication administration records (MAR), and emergency information. LPA reviewed a sample of clients' medications and observed facility have routine and PRN medications available to clients or order was sent to pharmacy. MAR was completed as medications were administered to clients.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted. A copy of this report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
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 4