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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608661
Report Date: 09/14/2022
Date Signed: 09/14/2022 03:53:05 PM

Substantiated


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: 4DATE:
09/14/2022
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Administrator-Brandy MaynardTIME COMPLETED:
04:10 PM
ALLEGATION(S):
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Client sustained multiple cigarette burns while in care.
Client sustained a fracture while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elsie Campos conducted a subsequent complaint visit to deliver findings for the above allegations. The LPA met with Administrator Brandy Maynard and explained the reason for the visit.

Allegation
Neglect/Lack of Supervision – Client sustained multiple cigarette burns while in care; and, Client sustained a fracture while in care.

On 02/25/2022, the Department received a complaint regarding an allegation of Neglect/Lack of Supervision. It was alleged that Client #1 (C1) sustained unexplained injuries consisting of multiple cigarette burns and a fractured nose. It is unknown whether the injuries were self-inflicted or caused otherwise. The complaint was referred to the Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Lorraine Patterson.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
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 5
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: 09/14/2022
NARRATIVE
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On 02/28/2022, from 2:05 p.m. to 5:15 p.m., Licensing Program Analyst (LPA) Elsie Campos conducted an unannounced initial 10-day complaint visit at the facility regarding the above allegation. At 2:05 p.m., LPA Campos met with Brandy Maynard, Administrator and explained the reason for the visit. During the inspection, the LPA conducted a physical plant tour with the Administrator at 2:08 p.m. and conducted a record review beginning at 2:30 p.m. There were three (3) staff and four (4) residents present. The LPA reviewed records for four (4) residents and obtained pertinent copies. The Administrator was notified that the complaint was referred to the Community Care Licensing Investigations Branch (IB) and assigned to Investigator Lorraine Patterson.

On 03/11/2022, at approximately 1:13 p.m., Investigator Patterson conducted interviews with the reporting party; on 06/21/2022, from approximately 11:19 a.m. to 11:40 a.m., with C1 and facility staff; on 06/27/2022, from approximately 10:30 a.m. to 2:11 p.m., with C1’s conservator/representative and Administrator; and on 06/28/2022, at approximately 11:11 a.m., with facility staff. Additionally, Investigator Patterson reviewed C1’s facility file documents, incident reports, photographs, and UCLA Health System medical records.

According to the Physician Report, dated 09/27/2021, C1’s diagnoses includes Schizophrenia, Mild Intellectual Disabilities, Psychosis, Seizure Disorder, Insomnia and Leukodystrophy. C1 is non-ambulatory, uses wheelchair, and requires assistance with activities of daily living (ADLs). C1 also has behaviors due to neurological issues which include verbal and physical aggression, property destruction and self-injurious (SIB) behavior.

On 02/22/2022, the Administrator submitted a Special Incident Report (SIR) listing the incident date involving C1 as 02/14/2022 at 5:45 a.m. The Administrator reported that on 02/15/2022, C1’s conservator/representative contacted the facility and reported that C1 had a bruise on C1’s nose. C1’s conservator/representative observed C1 with a bruised, purple and puffy nose. On 02/15/2022, during C1’s routine doctor appointment, C1’s conservator/representative asked that all C1’s extremities be examined. An X-ray was taken of the nasal bone and the Dr. confirmed that C1 sustained a minimally displaced fracture of the nasal bone. The Administrator followed up with facility staff #1 (S1) who reported that during a routine transfer C1 rolled and fell face forward from bed onto a fall/injury prevention mat next to C1’s bed.

Continued on LIC 9099-C
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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: 09/14/2022
NARRATIVE
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No injuries were visible. The Administrator further documented that the prevention mat is placed on the floor because this type of occurrence happens commonly. A review of the facility progress notes found that there was no documentation that C1 had sustained a fall as reported by S1. After the incident, the Administrator conducted lift and transfer support training and reporting procedures training for facility staff.

During the 02/15/2022 Dr. visit, the Dr. also noted C1 to have multiple and ongoing superficial cigarette burns. Based on C1’s limited and poor motor skill abilities, C1 needs to be monitored while in care. The Dr. noted when C1 smokes, the facility staff should be monitoring C1. Due to the multiple superficial cigarette burns observed on parts of C1 ‘s body and cigarette holes in sweater, it appeared to the Dr. that the facility staff do no monitor C1 to make sure C1 is safe when C1 smokes. The goal is to get C1 to stop smoking but this has not happened yet. Currently the Dr’s. order is for C1 to have two (2) cigarettes per 8-hour shift and C1 must be observed.

During the course of the investigation, it was disclosed from C1’s physician that over the past year, C1 has presented with multiple cigarette burns. On 02/15/2022, during a routine Dr. visit, C1 presented with a nose injury which confirmed a nose fracture. C1 and C1’s conservator/representative told the physician that the cigarette burn marks occur when the facility staff does not watch C1 while smoking. Facility staff denied any neglect or abuse and reported that C1 is allowed to smoke and the progression of C1’s diagnoses has led to C1’s cigarette burn marks and falls. Interviews and record review revealed that a plan of correction was recently put in place regarding providing adequate staffing, based on the North Los Angeles County Regional Center’s (NLACRC) staffing ratio requirements pertaining to C1. Based on C1’s Individual Program Plan (IPP), in addition to the 1:1 staffing requirement, C1 requires an additional staff eight (8) hours per day to assist with transfers. C1 needs two (2) persons to assist with transfer to ensure safety. Per the Administrator, C1 is currently pending transfer to a higher level of care since C1’s needs are higher than the other clients in the facility’s care.

Continued on LIC 9099-C
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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: 09/14/2022
NARRATIVE
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Investigator Patterson found a preponderance of evidence which revealed the allegation occurred, leading up to the facility’s implementation of recent safety/corrective changes made; therefore, the allegations, Client sustained multiple cigarette burns while in care; and, Client sustained a fracture while in care’ are deemed Substantiated at this time.

A $500 immediate civil penalty is assessed today. The Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1548 (c)(1).

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/16/2022
Section Cited
CCR
80078(a)
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80078 (a) Responsibility for Providing Care and Supervision. (a) The licensee shall provide care and supervision as necessary to meet the client’s needs. This requirement was not met as evidenced by:
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Licensee will submit a plan to provide proper level of care and supervision to ensure client needs are met. Submit to CCL by 9/16/2022.
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Based on interviews and record review, the licensee did not comply with the section above as C1 ended up with cigarette burns due to lack of observation. And, due to an inappropriate transfer, C1 sustained a nose fracture. This poses an immediate health and safety risk to residents in care.
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An immediate civil penalty of $500 is issued in accordance with California Health and Safety Code Section 1548(c)(1)

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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: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5