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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200593
Report Date: 04/11/2025
Date Signed: 04/11/2025 10:25:59 AM

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
03/21/2025 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20250321153917
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:
04/11/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jane Uwakwe, Interim Administrator TIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Staff did not allow client to attend their day program
INVESTIGATION FINDINGS:
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On 04/11/2025 at 9:00AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver findings for the above allegations. LPA explained the purpose of the visit with Interim Administrator Jane Uwakwe.

On the allegation facility Staff did not allow client to attend their day program: During the course of investigation, LPA obtained information, collected documents and interviewed staff and witnesses. Based on interview with staff (S1), and email communications, that the facility made the choice to not let R1 go to the day program and did not confer with R1 or R1's responsible party.

Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 has been cited.

Exit interview conducted. A copy appeal rights, and this report provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2025
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-20250321153917
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: 04/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/18/2025
Section Cited
CCR
87872(a)(6)
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(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (6) To leave or depart the facility at any time.
This requirement was not met as evidenced by:
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Administrator agrees to review the regulations and send in a self certified letter of understanding to CCLD by POC date.
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The facility staff not allowing R1 to attend their day program.
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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: 04/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2