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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200634
Report Date: 01/13/2023
Date Signed: 01/13/2023 04:08:13 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
05/04/2022 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20220504115915
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:
01/13/2023
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Rebecca Whitley, New AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff improperly restrain resident
Staff speaks inappropriately to resident
Facility does not meet residents' dietary needs
INVESTIGATION FINDINGS:
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On 01/13/2023, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to deliver findings for the above allegations. LPA met with Administrator Rebecca Whitley and informed her the purpose of the visit.

During the course of investigation, LPA conducted records review and interview. Based on records review there was no incident report regarding clients being handled in rough manner, the facility does not have incident report of any type of clients bruising from an inappropriate restrained. Based on staff interview, they are not aware of any staff handling anyone roughly. Staff stated that they have not witnessed or heard any staff acting inappropriate behavior towards clients in care and staff denied observing any staff yelling at the clients in care. LPA attempted to interview clients, but clients are non-verbal.

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

DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
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-20220504115915
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
VISIT DATE: 01/13/2023
NARRATIVE
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Based on interview and records review, facility have an available weekly menu. Based on interview with staff, the lead staff schedules staff who will be assigned in the kitchen. Staff stated that 90% of the time they follow what the dietitian wrote on the weekly menu so that the clients have variety of food. If in case the staff do not have the ingredients that is on the menu, the staff will substitute it with the similar food. Based on records review two clients (C2 & C1) are under regular diet and C3 is under low sodium diet, based on interview with staff, there is always low sodium food available for C3.

LPA observed during the visit that residents are comfortable, well dressed and staff are attending to each resident.



Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

Exit interview conduct and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2