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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608664
Report Date: 02/21/2023
Date Signed: 02/21/2023 04:11:25 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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/15/2023 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20230215111811
FACILITY NAME:ELWYN NC - KELVIN 2FACILITY NUMBER:
197608664
ADMINISTRATOR:AUGUSTINE ONUMAJURUFACILITY TYPE:
735
ADDRESS:6532 KELVIN AVETELEPHONE:
(747) 900-6197
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY:4CENSUS: 4DATE:
02/21/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff are not properly trained.
Facility staff files are incomplete.
INVESTIGATION FINDINGS:
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This is an amendment to change findings from Needs Further Investigation to Unsubstantiated.
Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to this facility to investigate the above allegations. LPA met with the Licensed Vocational Nurse, Maria Cervantes, and explained the reason for the visit.

--- Staff are not properly trained.

It was alleged that staff do not have proper training. To investigate the above allegation, LPA conducted physical plant tour at around 1:45 PM, requested pertinent documents at 2:10 PM, interviewed three (03) staff 2:20 PM – 2:35 PM and reviewed records from around 2:40 PM – 3:45 PM. During interviews with staff, they stated that clients do not require any medical attention or restraints.

(CONT. on LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023
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 31-AS-20230215111811
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ELWYN NC - KELVIN 2
FACILITY NUMBER: 197608664
VISIT DATE: 02/21/2023
NARRATIVE
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During record review, LPA confirmed that all staff have program related trainings and certificates. Based on interview and record review, there is not enough information to verify the allegation, therefore, the allegation is UNSUBSTANTIATED at this time.

---Facility staff files are incomplete.

It was alleged that staff files are incomplete. To investigate the above allegation, LPA conducted physical plant tour at around 1:45 PM, requested pertinent documents at 2:10 PM, interviewed three (03) staff 2:20 PM – 2:35 PM and reviewed records from around 2:40 PM – 3:45 PM. During interviews with the Administrator, they stated that all staff have necessary training and all records are complete. During record review, LPA confirmed that all staff files are complete. Based on interview and record review, there is not enough information to verify the allegation, therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards noted during the visit.

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2