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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608661
Report Date: 09/29/2022
Date Signed: 09/29/2022 11:01:51 AM

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
09/22/2022 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20220922141140
FACILITY NAME:ELWYN NC - KELVIN 1FACILITY NUMBER:
197608661
ADMINISTRATOR:BRANDY C MAYNARDFACILITY TYPE:
735
ADDRESS:5651 KELVIN AVETELEPHONE:
(747) 900-6742
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:4CENSUS: 4DATE:
09/29/2022
UNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Brandy MaynardTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Licensee failed to follow the facility's Plan of Operation
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced 10-day complaint visit for the above allegation. The LPA spoke with Administrator Brandy Maynard explained the reason for the visit. Today, the LPA interviewed staff at 9:15 a.m. and obtained documents.

It was alleged that this facility failed to ensure there was a licensed staff for every shift, per the facility’s program design. It was also alleged that staff failed to have proper training certifications prior to providing care to clients. Interviews and documentation confirmed that Staff #1 (S1) is the only licensed staff in the facility at this time. Given that, S1 is unavailable to work every shift and covers evening and weekend shifts. In addition, staff confirmed that Staff #2 (S2) did not have Direct Support Professional (DSP) II certification prior to hire, as detailed in the facility’s program design. The Administrator confirmed there was a staffing shortage and have since implemented a plan to ensure sufficient coverage, as well as a plan to ensure staff have the mandatory training completed as required prior to employment. Therefore, this allegation is deemed Substantiated at this time. Deficiencies cited (See 9099-D). Exit interview conducted. Copy of report and appeal rights issued.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
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 2
Control Number 29-AS-20220922141140
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: 09/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/04/2022
Section Cited
CCR
80022(f)
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80022(f) Plan of Operation. The facility shall operate in accordance with the terms specified in the Plan of Operation and may be cited for not doing so.
This requirement is not met as evidenced by:
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The Administrator has agreed to the following:
1. Submit a Plan of Action, detailing the efforts in meeting required staffing requirements (ie. licensing staff on all shifts; having certified staff upon hire). Submit Plan no later than 10/4/2022, end of day.
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Based on interview and record review, the licensee did not comply with the section cited above, as there was not a licensed staff on every shift, nor had all staff completed the required training prior to hire, which poses an potential 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: 09/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2