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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608661
Report Date: 08/28/2024
Date Signed: 08/28/2024 04:47:09 PM

Document Has Been Signed on 08/28/2024 04:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ELWYN NC - KELVIN 1FACILITY NUMBER:
197608661
ADMINISTRATOR/
DIRECTOR:		BRANDY C MAYNARDFACILITY TYPE:
735
ADDRESS:5651 KELVIN AVETELEPHONE:
(747) 900-6742
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 4CENSUS: 4DATE:
08/28/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Christian OkpalaTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angela Barutyan conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20240822111237). The purpose of the visit is to issue citations for a deficiency observed during the initial complaint investigation.

During the visit on 08/28/2024, LPA Barutyan and North Los Angeles County Regional Center (NLACRC), Quality Assurance Specialists (QASs) Lisseth Carrillo and Miguel Aguilar observed four (4) medication errors during medication review between 11:30AM-12:30PM. During medication review for Client 1 (C1), it was observed that the medication Almacone was logged as administered two (2) times on 08/22/2024 at 3PM and 8PM, however, Almacone was logged as administered twice on 08/21/2024 on the medication administration record. The 8PM entry for the medication was observed crossed out with pen. The medication Loperamide was logged as administered three (3) times, two (2) times on 08/22/2024 and one (1) time on 08/24/2024 but was logged on the medication administration record as one (1) time on 08/22/2024 and one (1) time on 08/24/2024. It was observed that C1 has a daily prescription medication, Senna and Docusate, for constipation. Further review of the medication information pamphlet revealed that the medication should not be administered if there has been a change in bowel movements for longer than two (2) weeks, which C1 has been experiencing.

The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiency may result in civil penalties.

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

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/28/2024 04:47 PM - It Cannot Be Edited


Created By: Angela Barutyan On 08/28/2024 at 03:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELWYN NC - KELVIN 1
FACILITY NUMBER: 197608661

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/29/2024
Section Cited
CCR
80075(b)(5)(B)

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Health Related Services. Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
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Administrator agreed to schedule a medications training with a qualified professional and send the date of the training to LPA Phillips by 08/29/24.
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Based on medication review, the Licensee did not comply with the section cited above in that 4 medication errors were made, which poses an immediate health, safety or personal rights risk to persons 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.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Angela Barutyan
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024


LIC809 (FAS) - (06/04)
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