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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608661
Report Date: 06/02/2022
Date Signed: 06/02/2022 04:08:22 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
02/05/2021 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20210205080839
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:
06/02/2022
UNANNOUNCEDTIME BEGAN:
02:57 PM
MET WITH:Brandy C Maynard, Administrator TIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff caused injuries to resident
Resident sustained multiple falls while in care due to lack of care and supervision
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Emily Peraldi conducted a subsequent complaint visit to deliver findings for the above allegation. At 2:55 p.m., LPA met with Administrator, Brandy C Maynard and explained the reason for the visit.

On 02/05/2021, the Department received a complaint regarding an allegation of physical abuse. It was alleged that Client #1 (C1) sustained multiple injuries by Staff #1 (S1) including a swollen pinky on left hand, and black eye. The complaint was referred to Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Dennis Douglas.

On 02/08/2021, from 10:30am to 11:00am, Licensing Program Analyst (LPA) Eva Miller conducted the initial 10-day complaint visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation was conducted virtually with the use of "FaceTime" with Direct Support Staff Joseph Hernandez. Continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
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-20210205080839
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: 06/02/2022
NARRATIVE
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LPA Miller requested and was provided a tour of the physical plant. The LPA conducted a telephonic interview with the Administrator Jamie Smith and requested specific facility documents pertinent to the investigation. The LPA advised the Administrator that the investigation was assigned to Investigator Dennis Douglas, CDSS Investigations, and that further investigation was required.

On 02/11/2021, from approximately 11:30am to 1:00pm, Investigator Douglas conducted interviews with C1, staff, and clients; and on 03/11/2021, at approximately 6:30pm, with the reporting party. Additionally,
Investigator Douglas reviewed C1’s facility file which included a copy of the Individual Program Plan (IPP) Progress Report dated 03/02/2018; Behavior Progress Report dated 11/16/2020 for the review period of 08/01/2020 – 10/31/2020; and body check forms which documented various injuries observed on C1 for the period of 07/12/2020 through 02/02/2021.

The information revealed C1 has diagnoses of Mild Intellectual Disability, Epilepsy, and Schizoaffective Disorder. The IPP indicated C1 expresses “self-injurious” behavior causing injury requiring first aid or medical care. The Behavior Progress Report indicated 26 occurrences of self-injurious behaviors by C1 within the review period of 08/01/2020 – 10/31/2020. Those behaviors were noted as cutting, hitting self, jumping out of a moving vehicle as well as inserting items into mouth. Other behaviors noted were banging head, biting hand, throwing self on the ground out of wheelchair, and pulling own hair. The report also indicated that no injuries were reported.

During the course of the investigation, it was disclosed that C1 was observed with a bruise on face and swollen left pinky by C1’s Representative. C1 informed C1’s Representative that facility staff members hit C1 causing a swollen left pinky and bruise to face. However, when Investigator Douglas interviewed C1, C1 stated no staff members ever hit C1 and stated they self-inflicted own injuries because they were mad and no longer wanted to be at the facility. Facility staff, as well as other facility clients stated C1 exhibits behavioral issues in which C1 self-injures. S1 was interviewed and denied ever hitting C1 causing injury. S1 explained that they arrived on shift and observed that C1 already had a bruise on eye. S1 stated the staff member from the prior shift was already aware of the bruise and notified S1 of the bruise. It was believed that C1’s bruise was self-inflicted. S1 admitted not documenting the bruise because it appeared old. S1 explained they had not worked at the facility the entire week prior, so they presumed it had already been documented. When S1 was asked why C1 would make the claim that S1 hit C1, S1 explained sometimes C1 likes you, sometimes not.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20210205080839
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: 06/02/2022
NARRATIVE
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During the investigation, C1’s Representative was also interviewed and acknowledged that C1 has a history of making false claims. C1’s Representative stated they did not believe that staff members were the cause of the injuries sustained by C1.

Based on the information obtained during the course of the investigation, the allegation of Physical Abuse is deemed Unsubstantiated at this time.

Regarding the allegation: Resident sustained multiple falls while in care due to lack of care and supervision.
It was also alleged that Client #1 (C1) sustained multiple falls while in care due to lack of care and supervision.

On 04/23/2022, Licensing Program Analysts (LPAs) Emily Peraldi, Elsie Campos and Ashley Smith conducted an unannounced subsequent complaint visit at the facility today. Between 10:00 a.m.- 10:30 a.m., LPA Peraldi and LPA Campos toured the facility, reviewed records and obtained copies of pertinent documents. Between 10:15 a.m. – 12:01 p.m., LPAs interviewed residents and staff. LPA Peraldi determined further investigation was required prior to issuing findings.

On 05/20/2022, LPA Peraldi reviewed C1’s Daily Progress Notes from 04/01/2021 - 06/30/2021. Within the time periods of 04/01/2021-06/30/2021, the Daily Progress Notes indicated seven (7) occurrences of behaviors such as throwing self out of the wheelchair and onto the ground. During the behaviors, the Daily Progress Notes indicated that staff would redirect C1 during the incidents, attempt to calm C1 down, and ensured C1 landed on a matt. Additionally, on 05/02/2022, interview with North Los Angeles Regional Center Community Services Supervisor conducted by LPA Smith revealed that behaviors of C1 include throwing self all over the place.

Based on record review and interviews, it is documented that C1 has a history of behaviors that include, but not limited to, throwing themselves on to the ground. It was also determined staff are present during the behaviors and try to intervene as much as possible to ensure the safety of C1. Based on the information obtained during the course of the investigation, the allegation above is deemed Unsubstantiated at this time.
Exit interview conducted, appeal rights and a copy of this report issued via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
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
02/05/2021 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20210205080839

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:
06/02/2022
UNANNOUNCEDTIME BEGAN:
02:57 PM
MET WITH:Brandy C Maynard, Administrator TIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff not providing adequate care and supervision to resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Emily Peraldi conducted a subsequent complaint visit to deliver findings for the above allegation. At 2:55 p.m., LPA met with Administrator, Brandy C Maynard and explained the reason for the visit.

On 02/05/2021, the Department received a complaint regarding an allegation of lack of care and supervision. It was alleged that the staff do not provide adequate care and supervision to resident.

On 02/08/2021, from 10:30am to 11:00am, Licensing Program Analyst (LPA) Eva Miller conducted the initial 10-day complaint visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation was conducted virtually with the use of "FaceTime" with Direct Support Staff Joseph Hernandez. LPA Miller requested and was provided a tour of the physical plant. The LPA conducted a telephonic interview with the Administrator Jamie Smith and requested specific facility documents pertinent to the investigation. LPA determined further investigation was required.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
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-20210205080839
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: 06/02/2022
NARRATIVE
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On 04/23/2022, Licensing Program Analysts (LPAs) Emily Peraldi, Elsie Campos and Ashley Smith conducted an unannounced subsequent complaint visit at the facility today. Between 10:00 a.m.- 10:30 a.m., LPA Peraldi and LPA Campos toured the facility, reviewed records and obtained copies of pertinent documents. Between 10:15 a.m. – 12:01 p.m. LPAs interviewed residents and staff. LPA Peraldi determined further investigation is required prior to issuing findings. In addition, interviews were conducted with a regional center liaison on 5/2/2022 at 1:16 p.m. and 05/27/2022, at 1:40 p.m., and with a resident responsible party on 4/23/2022 at 1:28 p.m.

During the subsequent visit at 9:54 a.m., on 04/23/2022, LPA Peraldi and LPA Campos observed Client #1 (C1) alone at the front of the facility smoking a cigarette. Once the LPAs gained entrance to the facility, they asked staff why C1 was outside alone. At 9:56 a.m., a staff went outside to be with C1. On 04/23/2022, LPA Peraldi conducted a record review that included C1’s most current (03/26/2021) Individual Program Plan (IPP) from the North Los Angeles Regional Center. The record review revealed that C1 requires 1:1 staffing In Lieu of Day Program (ILODP) six (6) hours/day, Monday through Friday and with an additional staff 8 hours/day Monday through Friday for transfer assistance. C1 also receives 1:1 staffing 16 hours/day Saturday and Sunday. The IPP does not document the definition of 1:1 other than ILODP. However, on 04/23/2022, staff interviews revealed C1 does need staff around at all times since C1 has a history of self-harm. The IPP indicated C1 expresses “self-injurious” behavior causing injury requiring first aid or medical care. Those behaviors were noted as cutting, hitting self, banging head, biting hand, throwing self on the ground out of wheelchair, and pulling own hair. Additionally, C1 requires assistance with transfers.

Based on LPAs observation on 04/23/2022, at 9:54 a.m., when LPAs observed C1 was alone outside in the front of the facility without staff being present, as well as record reviews and interviews, it has been determined C1 requires 1:1 staffing, with additional support from staff for transfer assistance. Based on the information obtained, there is sufficient evidence to support the allegation that the facility staff failed to provide adequate care and supervision to resident. 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: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20210205080839
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: 06/02/2022
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, observations and record review, the licensee failed to provide adequate care and supervision to client, 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: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6