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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200601
Report Date: 04/15/2022
Date Signed: 04/15/2022 05:13:39 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
07/07/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20210707155031
FACILITY NAME:ELWYN CALIFORNIA - MARIAFACILITY NUMBER:
079200601
ADMINISTRATOR:SANCHEZ, CATHERINE (CATHY)FACILITY TYPE:
734
ADDRESS:1364 MARIA AVETELEPHONE:
(408) 558-1500
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:4CENSUS: 4DATE:
04/15/2022
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Desiree Hufalar, Administrator
Ritchie Villapando, Staff		TIME COMPLETED:
05:35 PM
ALLEGATION(S):
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Staff member did not treat resident with dignity and respect
Staff member yelled in front of residents
INVESTIGATION FINDINGS:
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On 04/15/22 at 4:30PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent visit and delivered investigation findings. LPA explained the purpose of the visit with staff (S1) and spoke to administrator on the phone who authorized S1 to act on her behalf and sign the reports.

Allegation: Staff member did not treat resident with dignity and respect
Investigation Finding: SUBSTANTIATED
Based on interviews and record reviews, staff (S2) did not treat client (C1) with dignity and respect when she raised her voice at C1’s family member and reacting adversely for client’s family member not getting permission from S2 prior to taking C1 for short walks outside the facility on 07/05/21. C1’s family member also got upset when S2 removed C1’s shirt in the common area of the home in the process of feeding C1. The preponderance of evidence has been met. Therefore, this allegation is substantiated.
Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
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-20210707155031
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 - MARIA
FACILITY NUMBER: 079200601
VISIT DATE: 04/15/2022
NARRATIVE
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Allegation: Staff member yelled in front of residents
Investigation Finding: SUBSTANTIATED
Based on interviews and record reviews, staff (S1) confirmed with LPA that he witnessed staff (S2) engage in a heated exchange of words with C1’s family member that took place in the front entrance of the facility with C1 and another family member present on 07/05/21. The preponderance of evidence has been met. Therefore, this allegation is substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POCs) 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 via email.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20210707155031
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 - MARIA
FACILITY NUMBER: 079200601
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/29/2022
Section Cited
CCR
80072(a)(1)
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To be accorded dignity in his/her personal relationships with staff and other persons. This requirement was not met as evidenced by staff not treating client with dignity & respect
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By POC due date, administrator agrees to conduct in-service staff retraining on how to effectively communicate with client’s authorized representative and how to respect client’s privacy needs. Administrator agrees to submit completed staff retraining certifications to CCLD by POC due date.
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which posed a potential health & safety risk to clients in care
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Type B
04/29/2022
Section Cited
CCR
80072(a)(3)
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To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: 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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By POC due date, Administrator agrees to submit to CCLD completed in-service staff retraining on proper communication techniques with authorized representatives and will submit to CCLD copy of completed staff retraining.
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This requirement was not met as evidenced by staff yelling at client which posed a potential health & safety risk to clients 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: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3