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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608661
Report Date: 06/01/2022
Date Signed: 06/01/2022 04:54:50 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
11/24/2021 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20211124163604
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: 4DATE:
06/01/2022
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Crystal CortesTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility staff did not safeguard residents' personal belongings.
Facility staff did not treat residents with dignity and respect.
Facility is in financial distress.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Ashley Smith arrived unannounced to deliver the findings for the above allegations. The LPA met with staff and explained the reason for the visit.

During the initial visit conducted on 11/29/2021, the LPA conducted a physical plant tour at 1:54 p.m., interviewed staff at 1:40 p.m., 2:01 p.m., 2:09 p.m., 2:28 p.m., and 2:43 p.m.; and, interviewed residents at 3:10 p.m., 3:24 p.m., and 3:44 p.m. During a subsequent visit conducted on 4/23/2022, the LPAs toured the facility, reviewed records, obtained documents and from 10:15 a.m. – 12:01 p.m., the LPAs interviewed residents and staff. In addition, interviews were conducted with a regional center liaison on 5/2/2022 at 1:16 p.m. and 5/27/2022 at 1:40 p.m., and with a resident responsible party on 4/23/2022 at 1:28 p.m.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
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 6
Control Number 29-AS-20211124163604
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: 06/01/2022
NARRATIVE
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Regarding the allegation: Facility staff did not safeguard residents' personal belongings.
It was alleged that during a room rearrangement, personal belongings for clients were misplaced or thrown away. Specifically, for C1, it was alleged that C1’s personal items went missing. Client interviews confirmed claims that staff assisted clients with cleaning and rearranging their rooms, but most clients denied claims that items went missing. Staff interviews revealed inconsistent information as to whether some of C1’s items went missing. Staff claimed that some clients agreed to donating some items and throwing away others, yet there was insufficient evidence to support that items for C1 were missing. Staff stated that C1 would oftentimes throw things away. An interview with R1’s responsible party revealed that if items of C1 had gone missing, they were retrieved or replaced. It was communicated that there were no immediate concerns regarding C1’s personal belongings. Based on the information obtained during the course of the investigation, there is insufficient evidence to support the claim that staff did not safeguard residents' personal belongings. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Facility staff did not treat residents with dignity and respect.
It was alleged that staff failed to treat clients with dignity and respect, as the client’s rooms were re-arranged, and items were thrown out without their consent. Client interviews revealed that in general, clients were aware that their rooms were going to be rearranged and organized for their benefit. Clients corroborated claims that they agreed to either throw away or donate items and that it was done with their consent. In general, clients felt that the staff treated them with dignity and respect. For clients whom expressed concern regarding their interactions with staff, the LPA observed that the licensee had submitted Special Incident Reports (SIRs) to document the above-mentioned interactions and/or incidents. Whereas another client commented on how they wanted the color of their room painted, they did not indicate that staff failed to treat them with dignity or respect. Based on the information obtained, there is insufficient evidence to support the claim that staff did not treat residents with dignity and respect. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Facility is in financial distress


It was alleged that staff did not have access to the petty cash and instead had to be reimbursed for purchases. Interviews revealed that upon the arrival of the current Administrator in October 2021, the Administrator decided to limit the amount of persons that had access to the petty cash for security purposes.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20211124163604
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: 06/01/2022
NARRATIVE
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Interviews revealed that if staff needed items for the home, they could inform the Administrator in a timely manner and the Administrator would assure that items were delivered to the home. In general, staff communicated that if they had to pay for items out of pocket, they would be reimbursed by the Administrator. In addition, staff and clients communicated no concerns regarding the client’s P&I money and stated that it was kept locked and inaccessible in the facility cabinet. Based on the information obtained, there is insufficient evidence to support the claim that the facility was in financial distress. This allegation is deemed Unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
11/24/2021 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20211124163604

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: 4DATE:
06/01/2022
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Crystal CortesTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Insufficient staffing to meet resident needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Ashley Smith arrived unannounced to deliver the findings for the above allegations. The LPA met with staff and explained the reason for the visit.

During the initial visit conducted on 11/29/2021, the LPA conducted a physical plant tour at 1:54 p.m., interviewed staff at 1:40 p.m., 2:01 p.m., 2:09 p.m., 2:28 p.m., and 2:43 p.m.; and, interviewed residents at 3:10 p.m., 3:24 p.m., and 3:44 p.m. During a subsequent visit conducted on 4/23/2022, the LPAs toured the facility, reviewed records, obtained documents and from 10:15 a.m. – 12:01 p.m., the LPAs interviewed residents and staff. In addition, interviews were conducted with a regional center liaison on 5/2/2022 at 1:16 p.m. and 5/27/2022 at 1:40 p.m., and with a resident responsible party on 4/23/2022 at 1:28 p.m.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20211124163604
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: 06/01/2022
NARRATIVE
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Regarding the allegation: Insufficient staffing to meet resident’s needs
The complainant alleged that there have been multiple incidents where the home was understaffed and unable to meet 1:1 staffing ratio as required. Of the four clients that reside in the facility in November 2021, the facility has two individuals that require 1:1 staffing (Client #1, Client #2). A review of C1’s Individual Program Plan (IPP) and an interview with C1’s service coordinator confirmed that in addition to the 1:1 staffing requirement for C1, C1 needs an additional staff eight (8) hours a day, Monday through Friday, to assist with transfers. As such, C1 needs two persons to assist with transfers to ensure C1’s safety. Lastly, C2’s Individual Program Plan (IPP) document dated 1/12/2022 noted that C2 no longer required 1:1 care.

Staff interviews revealed that when staff called off, other staff were asked to cover or work double shifts. If staff commented that there was an understaffing issue, it was because the same staff were being asked to work overtime, which may indicate that the facility needs more staff. Staff interviews confirmed that at the time the complaint was submitted to the Department, the facility had experienced a lot of call outs, staff admitted that there typically are two persons working during a shift, and some staff claimed to have worked alone during NOC shift, despite the scheduling sheet. A review of schedules for the week of 11/29/2021-12/5/2021 revealed that on 11/29/2021, there were only two staff for the AM shift and only two staff for the PM shift. On 12/1/2021 and 12/5/2021, there were only two staff for the PM shift. Given the needs for clients that required 1:1 care, the facility needed at least three staff for the AM and PM shift, and an additional staff to assist with transfers for C1. The majority of staff confirmed that they had transferred C1 alone due to the lack of staffing. Based on the information obtained, there is sufficient evidence to support the claim that the facility staff failed to be in the required staffing ratio. This allegation is deemed Substantiated at this time.

The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided via email.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20211124163604
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/03/2022
Section Cited
CCR
85065.5(a)(1)
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85065.5(a)(1) Day Staff-Client Ratio (1) For Regional Center clients, staffing shall be maintained as specified by the Regional Center but no less than one direct care staff to three such clients. This requirement is not met as evidenced by:
This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
1. Submit a Staffing Plan to CCL regarding how the facility plans to maintain sufficient staffing. Submit plan no later than 6/3/2022.
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Based on interview and record review, the licensee failed to follow staffing ratios as specified by the Regional Center, which poses an immediate health and safety risk to clients in care.
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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: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6