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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608664
Report Date: 02/06/2025
Date Signed: 02/06/2025 12:17:41 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
01/31/2025 and conducted by Evaluator Perchui Khurshudyan
COMPLAINT CONTROL NUMBER: 31-AS-20250131134348
FACILITY NAME:ELWYN NC - KELVIN 2FACILITY NUMBER:
197608664
ADMINISTRATOR:TAYO LABEODANFACILITY TYPE:
735
ADDRESS:6532 KELVIN AVETELEPHONE:
(747) 900-6197
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY:4CENSUS: 3DATE:
02/06/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Frances Tullao - LVNTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff did not ensure there was sufficient staff at the facility to meet the needs of clients in care
INVESTIGATION FINDINGS:
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On 2/6/2025 at 9:00am, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted an unannounced, initial 10-day visit to investigate the above allegation. Upon arrival, LPA met with the Tullao Frances - LVN, introduced herself by showing her badge, and explained the reason for the visit.

To investigate the complaint, LPA requested copies of client and staff rosters, clients’ files and obtained copies of pertinent documents which include, but not limited to Admission Agreement, Physician Reports, Individual Program Plan (IPP), and Approved Program design for the facility.
At 9:45am LPA requested and reviewed staff files and obtained copies of staff / DSP work schedules and shifts.
LPA conducted a physical plant tour at approximately 10:15am, and observed that the house is generally clean and organized.

Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025
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 3
Control Number 31-AS-20250131134348
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ELWYN NC - KELVIN 2
FACILITY NUMBER: 197608664
VISIT DATE: 02/06/2025
NARRATIVE
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It was reported that on 1/16/2025, credible witness from North LA County Regional Center (NLACRC) conducted an unannounced visit at Elwyn Kelvin 2 home and observed there was no licensed staff (LVN) scheduled for the NOC shift (11pm-7am) for that day and for the following weekends: 11/21/2024-11/23/2024,11/28/2024-11/30/2024,12/5/2024-12/7/2024,12/12/2024-12/14/2024,12/26/2024-12/27/2024, and 1/3/2025. This resulted failure of following the approved program design for the Health and Well Being of all clients and violation of the terms of the clients’ Admission Agreements.

LPA requested and reviewed facility Program Design, that was created and approved by the NLACRC, which indicates on page 31 that an LVN - Licensed Vocational Nurses or LPT - Licensed Psychiatric Technicians will always be in the home when residents are present.


Based on interviews and documentation review, there is enough evidence of confirming the allegation, therefore, this allegation is deemed to be Substantiated.

Deficiencies issued on LIC9099-D, Appeal rights provided.

Exit interview conducted and copy of this report printed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20250131134348
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELWYN NC - KELVIN 2
FACILITY NUMBER: 197608664
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/21/2025
Section Cited
CCR
85065(b)
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Personnel Requirements (b)The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs.
This requirement is not met as evidenced by:
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Licensee/Administrator is in process of hiring licensed staff for the facility, will submit
weekly staffing schedule reflecting the licensed staff on shifts.
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Based on observation, records review, and interviews, the licensee did not comply with the section cited above in ensuring to have licensed staff LVN coverage for all set shifts, which poses potential health, safety or personal rights risk to persons in care.
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Type B
02/21/2025
Section Cited
CCR
85078(a)(1)
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Responsibility for Providing Care and Supervision(a)In addition to Section 80078,(1)The licensee shall provide services identified in the client's needs and services plan...to meet the client's needs. This requirement is not met as evidenced by:


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Licensee/Administrator, will submit written program specifying the duties and responsibilities of the service provider to clients in care.
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Based on observation, records review, and interviews, the licensee did not comply with the section cited above, which poses potential 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.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3