079200593-8-27-2025-15-AS-HHUL-DLDM2E-20250910091325

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200593
Report Date: 08/27/2025
Date Signed: 08/27/2025 02:21:59 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
05/30/2025 and conducted by Evaluator Jill Clancy-Czuleger

COMPLAINT CONTROL NUMBER: 15-AS-20250530151456

FACILITY NAME:	ELWYN CALIFORNIA - KEITH		FACILITY NUMBER:	079200593
ADMINISTRATOR:	VIERNES, ADRIAN		FACILITY TYPE:	734
ADDRESS:	1141 KEITH DR		TELEPHONE:	(408) 558-1500
CITY:	CONCORD	STATE: CA	ZIP CODE:	94518
CAPACITY:	4	CENSUS: 4	DATE:	08/27/2025
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Ruby Abalos, Director of Nursing		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

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Staff did not notify authorized representatives resident was missing
Staff did not check on resident
Staff did not notify authorized representative of updates regarding the resident

INVESTIGATION FINDINGS:

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On 08/27/2025 at 12:30 PM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver findings for the above allegations. LPA explained the purpose of the visit with Staff member Bricia Castro. Director of Nursing Ruby Abalos joined later.

On the allegation: Staff did not notify authorized representatives resident was missing.
Based on interviews and records review, R1 went to the hospital on March 8th, 2025, and transferred to surgery the following day. On 3/25/2025 R1 was transferred to Diablo Valley Post Acute for the continuation of R1’s healing. Staff continued to check on R1 on and off. On 5/19/2025 AM staff dropped off clothes to R1 at Diablo Valley Post Acute and saw R1 asleep in bed. On 5/24/2025 staff called R1's cell phone but it did not ring, staff called Diablo Valley Post Acute but would not provide staff with information as they were not listed as the emergency contact. Facility staff emailed all involved with R1’s care that they were having trouble getting into contact with R1.

Continued on 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20250530151456

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: 08/27/2025

NARRATIVE

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On the allegation: Staff did not check on residents
Based on interviews and records review, the facility staff were checking in on R1 while at the hospital and continued to check in on R1 when R1 was moved to the Diablo Valley Post Acute, including dropping off clean clothes on 5/19/2025. On 5/24/2025 staff called R1's cell phone but it did not ring, staff called Diablo Valley Post Acute but would not provide staff with information as they were not listed as the emergency contact. Between 5/25/2025-5/30/2025 staff continued to attempt to make calls to Diablo Valley Post Acute and R1's cell with no success.

On the allegation: Staff did not notify authorized representative of updates regarding the resident.

Based on interviews and records review on Saturday, May 24, 2025 7:44 PM S3 sent an email to R1’s responsible party stating that calls were attempted to R1 but his phone was not ringing and when staff called Diablo Valley Post Acute and was able to speak to W1 LVN and asked to speak with to R1 but according to W1, R1 is not in the facility.S3 asked for an update but S3 was not listed as an emergency contact. A second attempt was made by S1 with the same result.

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: 08/27/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025

LIC9099 (FAS) - (06/04)

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