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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200601
Report Date: 02/08/2023
Date Signed: 02/08/2023 04:48:10 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
12/14/2021 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20211214160159
FACILITY NAME:ELWYN CALIFORNIA - MARIAFACILITY NUMBER:
079200601
ADMINISTRATOR:SANCHEZ, CATHERINE (CATHY)FACILITY TYPE:
734
ADDRESS:1364 MARIA AVETELEPHONE:
(925) 483-2792
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:4CENSUS: DATE:
02/08/2023
UNANNOUNCEDTIME BEGAN:
04:25 PM
MET WITH:Gloria Ombajin, House ManagerTIME COMPLETED:
04:55 PM
ALLEGATION(S):
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Facility does not have documentation of authority to make medical decisions for client.
INVESTIGATION FINDINGS:
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On 2/8/2023 at 4:25PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to deliver findings on the above allegation and met with Gloria Ombajin, House Manager and explained the purpose of the visit. LPA spoke with Administrator, Desiree Hulfalar, and was given approval for House Manager to sign report.

On 12/16/2021, LPA Alicia Delmundo conducted pre-investigation. On 12/21/2021, LPA Delmundo initiated 10-day investigation, obtained records and conducted interviews.
On 2/6/2023, LPA Luisa Fontanilla interviewed Administrator. Based on interview conducted, Administrator states that for R1’s routine visits, no authorization is needed. Administrator added R1 receives Depo shots every month thus no authorization is needed. But for other purposes such as vaccine, psychotropic medications and major medical decisions, Regional Center of the East Bay (RCEB) Case Manager (CM) gives the consent.

Continued on LIC9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
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-20211214160159
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: 02/08/2023
NARRATIVE
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Continued from LIC9099.

A review of an email sent by R1’s CM to LPA Delmundo on 12/21/2021 indicates that CM confirmed information provided by Administrator. RCEB is responsible in giving consents for vaccines, psychotropic medications, and major medical decisions. But RCEB does not do consents for every single medical activity and routine activities.

Based on interviews conducted and records reviewed, the above allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

There is no deficiency noted.

Exit interview conducted and a copy of this report provided

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2