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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609009
Report Date: 08/03/2022
Date Signed: 08/03/2022 12:41:33 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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/27/2022 and conducted by Evaluator Patrick Shanahan
COMPLAINT CONTROL NUMBER: 31-AS-20220727104556
FACILITY NAME:ELWYN CALIFORNIA - YARMOUTHFACILITY NUMBER:
197609009
ADMINISTRATOR:EDWARD VELARDEFACILITY TYPE:
735
ADDRESS:10512 YARMOUTH AVETELEPHONE:
(818) 488-1753
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:4CENSUS: 4DATE:
08/03/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Tayo Lebeodan/ AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff did not have first aide training
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility in response to the above mentioned allegation. LPA had his temperature taken and all covid-19 protocols were observed before allowing the LPA to enter the home. The LPA explained the reason for the visit.

Allegation 1..Staff did not have first aide training
LPA was able to speak to the administrator regarding this allegation. The administrator confirmed that on 7/6/2022, a Regional Center Inspection uncovered that one staff did not have sufficient first aide training. The administrator did show proof that the first aide training has since been completed, however the staff member did continued working with an expired first aide training.

Based on confirmation from the administrator, this allegation is deemed Substantiated at this time.

Exit interview conducted, deficiencies cited and report issued.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
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 31-AS-20220727104556
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 CALIFORNIA - YARMOUTH
FACILITY NUMBER: 197609009
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/04/2022
Section Cited
CCR
89965(k)(1)
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Personnel Requirements-Direct care staff shall maintain current certifications in first aid and cardiopulmonary resuscitation. The administrator shall maintain the certifications in the facility personnel records.
This requirement was not met as evidenced by:
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Facility staff has completed first aid training. Administrator provided the documentation during visit.

Cleared before visit.
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Based on interviews one facility staff did not have current first aid certificates on file could have posed a 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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2