079200634-3-17-2023-15-AS-HHUL-CS4V4P-20230523160640

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200634
Report Date: 03/17/2023
Date Signed: 03/17/2023 02:58:01 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
03/07/2023 and conducted by Evaluator Grace Luk

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230307081501

FACILITY NAME:	ELWYN CALIFORNIA - TERRA VERDE		FACILITY NUMBER:	079200634
ADMINISTRATOR:	WHITLEY, REBECCA L		FACILITY TYPE:	737
ADDRESS:	2934 TERRA VERDE LN		TELEPHONE:	(925) 418-4168
CITY:	OAKLEY	STATE: CA	ZIP CODE:	94561
CAPACITY:	4	CENSUS: 4	DATE:	03/17/2023
		UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Abiodun Fagorala, Lead Staff		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff's dog bit a client

INVESTIGATION FINDINGS:

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On 3/17/2023 at 8:55AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegation above. LPA met with Lead Staff, Abiodun Fagorala and informed him the reason for the visit.

During the course of investigation, LPA interviewed 4 clients, 10 staff, and 2 witnesses. LPA obtained and reviewed documents including clients' IPP (Individual Program Plan) and emergency contact information. Interview with clients and staff revealed that a staff's dog has been at the facility. However, staff did not witness an incident where a client was bitten by the dog.

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. A copy of this report provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023

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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