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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609009
Report Date: 02/25/2022
Date Signed: 02/25/2022 03:34:13 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,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/27/2020 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 31-AS-20200127130027
FACILITY NAME:ELWYN CALIFORNIA - YARMOUTHFACILITY NUMBER:
197609009
ADMINISTRATOR:SAMANTHA TODERFACILITY TYPE:
735
ADDRESS:10512 YARMOUTH AVETELEPHONE:
(818) 488-1753
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:4CENSUS: 4DATE:
02/25/2022
UNANNOUNCEDTIME BEGAN:
03:03 PM
MET WITH:George BedarianTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility staff did not follow physician's orders for resident in care
Facility staff did not seek appropriate medical attention in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent complaint investigation for the above allegations. Upon arrival LPA met with George Bedarian and explained the reason for the visit.

On 1/28/2020, LPA conducted the initial complaint visit and met with House Manager George Bedarian. During the initial visit, LPA conducted a tour physical plant, interviewed staff and residents. Additionally, LPA reviewed and obtained copies of pertinent documents relevant to the investigation.

It was alleged that facility staff did not follow physician’s order for Resident #1 (R1). It was further alleged that facility staff failed to seek appropriate timely medical attention for R1. During the course of the investigation, additional interviews were conducted with Cristina Perez with Regional Center.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022
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 3
Control Number 31-AS-20200127130027
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: ELWYN CALIFORNIA - YARMOUTH
FACILITY NUMBER: 197609009
VISIT DATE: 02/25/2022
NARRATIVE
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Continued from 9099

Based on information gathered, it was revealed that on 12/21/2019, Resident 1 (R1) was transported to the Emergency Room (ER) due to seizure activity that began at 1:08 a.m. At 1:15 a.m., R1 began to have to a series of back to back seizures each lasting 3-5 seconds. Records reviewed reflected that R1 had approximately ten (10) total seizures. S1 contacted facility administrator at 7:00 a.m. at which time the administrator instructed S1 to contact 9-1-1. Interviews conducted and records reviewed further reflected that, R1 has a Restricted Health Condition Care Plan (RHCCP), which states, “Administer 5-10 Liters/Minute oxygen via Adult Medium Mask as needed when having a seizure and call 9-1-1.” Based on interviews S1 did not administer oxygen to R1 as indicated physicians’ orders listed on RHCCP, and Medication Administration Record (MAR). Additionally, it was revealed that Emergency Services was contacted at 7:45 a.m. and paramedics did not arrive until 8:00 a.m. Based on all information gathered, S1 failed to follow physicians orders and obtain timely medical attention for R1; therefore, the above allegations are deemed SUBSTANTIATED at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D)

Exit interview conducted, appeal rights discussed, and a copy of this report issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20200127130027
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: ELWYN CALIFORNIA - YARMOUTH
FACILITY NUMBER: 197609009
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/25/2022
Section Cited
CCR
85078(a)(1)
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85078 (a)(1) Responsibility for Providing Care and Supervision (1)The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs.
This requirement was not met as evidenced by:
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Administrator provided documents that regulation 85078(a)(1) had been reviewed with staff and understood. Administrator also stated that S1 had been terminated shortly after the incident occurred. POC cleared during time of visit.
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Based on interviews and records review Licensee did not follow R1’s plan of care as oxygen was not administered and 9-1-1 was not called after R1 was having a seizure. This poses as 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: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3