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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200601
Report Date: 01/26/2023
Date Signed: 01/26/2023 02:38:22 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
06/09/2021 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20210609121126
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:
01/26/2023
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Desiree Hufalar, Administrator TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Resident sustained an injury while in care
INVESTIGATION FINDINGS:
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On 01/26/2023 at 12:30PM, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to deliver complaint findings for the allegation above. LPA met with Administrator Desiree Hufalar.

During the investigation, LPA reviewed documents such as but not limited to; Physician’s report, Doctor’s note for C1, facility’s progress notes, individual service plan (IPP) for C1. LPA also conducted interview with facility staff. LPA attempted to interview C1, but C1 is non-verbal client and did not answer LPA’s questions.

…Continue to LIC9099C…
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
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-20210609121126
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: 01/26/2023
NARRATIVE
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During the course of investigation, records review revealed one of C1’s historical behavior is self injurious behavior, where client tries to hurt herself, IPP plan also stated that C1 have inability to control movements.

On June 03, 2021, staff found skin discoloration on C1’s back, staff notified C1’s primary physician. Primary physician ordered staff to send C1 to the hospital for further evaluation. X-ray result revealed there is no fracture noted or any broken bones. Primary physician then ordered ointment to address C1’s bruise on her back. Although interviews and documents revealed that on June 3, 2021, C1 had bruise on her back, LPA do not have enough evidence that injury was sustained from staff abuse.

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 Desiree Hufalar. A copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2