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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608661
Report Date: 04/23/2022
Date Signed: 04/23/2022 02:15:44 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/25/2022 and conducted by Evaluator Elsie Campos
COMPLAINT CONTROL NUMBER: 29-AS-20220225154926
FACILITY NAME:ELWYN NC - KELVIN 1FACILITY NUMBER:
197608661
ADMINISTRATOR:JAIMIE LYNN SMITHFACILITY TYPE:
735
ADDRESS:5651 KELVIN AVETELEPHONE:
(747) 900-6742
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:4CENSUS: DATE:
04/23/2022
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Femi AdeniyiTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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The facility van registration has lapsed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst's (LPA's) Elsie Campos, Emily Peraldi and Ashley Smith conducted an unannounced subsequent complaint visit at the facility today regarding the above allegation. At 9:50 a.m., the LPA's met with Femi Adeniyi, House Manager and explained the reason for today's visit.

Between 10:00 a.m. - 10:30 a.m., LPA Peraldi and LPA Campos toured the faiclity, reviewed records and obtained copies of documents. Between 10:15 a.m.- 12:01 p.m., the LPAs interviewed residents and staff.


Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2022
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 3
Control Number 29-AS-20220225154926
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ELWYN NC - KELVIN 1
FACILITY NUMBER: 197608661
VISIT DATE: 04/23/2022
NARRATIVE
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Regarding the allegation: The facility van registration has lapsed.
The complainant was concerned that facility van is not licensed and does not have proper documentation to drive the van. Upon observation, it was noted that the facility has two vans. Staff interviews revealed that one of the two facility vans was obtained from out of state during the height of the pandemic. However, the facility has maintained appropriate registration for both vehicles. A record review confirmed that both facility vehicles are properly registered in the State of California and registration for both vehicles were valid at the time of the visit. Based on the information obtained, there is insufficient evidence to support the claim that the facility van registration has lapsed. This allegation is deemed Unsubstantiated at this time.

Exit interview conducted. A copy of the report was issued.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3