<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200634
Report Date: 03/28/2022
Date Signed: 03/28/2022 04:13:25 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
03/01/2021 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20210301114642
FACILITY NAME:ELWYN CALIFORNIA - TERRA VERDEFACILITY NUMBER:
079200634
ADMINISTRATOR:STEVENS, STACIFACILITY TYPE:
737
ADDRESS:2934 TERRA VERDE LNTELEPHONE:
(925) 418-4168
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY:4CENSUS: 3DATE:
03/28/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Staci StevensTIME COMPLETED:
04:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff mishandled a client while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 3/28/2022 at 1:00PM Licensing Program Analyst (LPA) L.Ibo arrived unannounced to deliver complaint findings for the allegation above. LPA met with Administrator, Staci Stevens.

During the course of investigation, LPA gathered the following documents but not limited to; SOC341, daily notes and termination document. Based on staff interview S1 was aggressive towards the resident in care, however, resident did not sustain any bruises or injuries. Facility suspended S1 on 3/9/2021 and was terminated on 3/10/2021.

Based on LPA information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.

Exit interview conducted. A copy of this report and appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022
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 2
Control Number 15-AS-20210301114642
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 - TERRA VERDE
FACILITY NUMBER: 079200634
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/08/2022
Section Cited
CCR
80072(a)(2)
1
2
3
4
5
6
7
Personal Rights. To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
This requirement is not met as evidence by:
1
2
3
4
5
6
7
Facility terminated staff (S1).
Administrator agreed to train all staff with the regulation cited above, a proof of training needs to be submitted to CCL office by POC date.
8
9
10
11
12
13
14
Based on investigation, licensee did not comply with the section cited above based on interview and records review, staff (S1) was aggressive towards resident in care which posed a potential health & safety risk to clients in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2