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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200601
Report Date: 12/14/2022
Date Signed: 12/14/2022 10:26:01 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
12/06/2022 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20221206134406
FACILITY NAME:ELWYN CALIFORNIA - MARIAFACILITY NUMBER:
079200601
ADMINISTRATOR:HUFALAR, DESIREE BFACILITY TYPE:
734
ADDRESS:1364 MARIA AVETELEPHONE:
(925) 483-2792
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:4CENSUS: 4DATE:
12/14/2022
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Desiree Huflar, Executive DirectorTIME COMPLETED:
10:40 AM
ALLEGATION(S):
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Facility staff yelled and screamed at resident.
INVESTIGATION FINDINGS:
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On 12/14/2022 starting at 09:10 am, Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to conduct complaint investigation for the above allegation. LPA met with RN Ritchie Villapando and explained the purpose of the visit. Executive Director, Desiree Huflar joined later.

During the course of investigation, LPA obtained information, collected documents and interviewed 2 staff. Based on interview with staff (S1, S2), it was revealed that the incident did occur where a staff member was yelling in the presence of a resident.

Based on LPAs interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D.

Exit interview conducted. Appeal Rights and a copy of this report provided.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
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-20221206134406
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: 12/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/14/2022
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...
This requirement was not met as evidenced by:
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The facility no longer emplyees the staff member and agrees to review licensing standards of personal rights with all staff.
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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: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
LIC9099 (FAS) - (06/04)
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