<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609009
Report Date: 02/20/2025
Date Signed: 02/20/2025 01:52:32 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
07/16/2024 and conducted by Evaluator Michael Cava
COMPLAINT CONTROL NUMBER: 31-AS-20240716123550
FACILITY NAME:ELWYN CALIFORNIA - YARMOUTHFACILITY NUMBER:
197609009
ADMINISTRATOR:TAYO LABEODANFACILITY TYPE:
735
ADDRESS:10512 YARMOUTH AVETELEPHONE:
(818) 488-1753
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:4CENSUS: 4DATE:
02/20/2025
UNANNOUNCEDTIME BEGAN:
09:38 AM
MET WITH:Yvette Cosme-AdministratorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not providing care to resident(s) as necessary to meet resident(s) needs while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Michael Cava conducted a subsequent visit to the facility to follow up on the above allegation. The initial visit by LPA Cava was made on 07/19/24. LPAs investigation consisted of staff and resident interviews and record review. It was alleged that the facility didn't have a required nurse (LVN/LPT), on shift, on 06/08/24 and 06/14/24. Reports received reveal that Resident 1 (R1), had seizures on those dates. Review of R1's Admission Agreement indicate that R1 will be provided continuous care and supervision. The facility's Program Design further state that there will be a nurse on site twenty-four hours per day "to provide direct care staffing levels that exceed the requirements of a Servicel Level 4I facility, which are consistent with the staffing levels and qualifications upon which this CPP development was approved" As a result of the nurse's absence, staff did not provide the care to R1 as necessary to meet R1's needs when they experienced seizures on 06/08/24 and 06/14/24. Based on further review, the above allegation remains Substantiated. Citation already issued on 07/19/24, and corrections were made on 08/24/24. No further citaitons issued at this time. Administrator advised and a copy of this report issued.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
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 2
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
07/16/2024 and conducted by Evaluator Michael Cava
COMPLAINT CONTROL NUMBER: 31-AS-20240716123550

FACILITY NAME:ELWYN CALIFORNIA - YARMOUTHFACILITY NUMBER:
197609009
ADMINISTRATOR:TAYO LABEODANFACILITY TYPE:
735
ADDRESS:10512 YARMOUTH AVETELEPHONE:
(818) 488-1753
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:4CENSUS: 4DATE:
02/20/2025
UNANNOUNCEDTIME BEGAN:
09:38 AM
MET WITH:Yvette Cosme-AdministratorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is not adhering to resident's Admission Agreement.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Michael Cava conducted a subsequent visit to the facility to follow up on the above allegation. The initial visit by LPA Cava was made on 07/19/24. At that time, the investigation was Substantiated. LPAs investigation consisted of staff and resident interviews and record review. It was reported that the facility did not have a required staff, or nurse, on shift, on 06/08/24 and 06/14/24. According to the facility's program design, "an LVN remains on duty until relieved by incoming staff". Report by another agency was received, and it revealed that on 06/08/24, Staff 1 (S1), called off, and Staff 2 (S2) was called to provide coverage. However, S2 left at approximately 9pm, which entails that the facility failed to follow their contigency plan, identified in the Program Design. Although the facility's Program Design indicates that an LVN will remain on duty until releived by incoming staff, R1's Agreement Agreement (AA) only specifies that R1 will receive Continuous Care and Supervision. No specification indicated on R1's AA that R1 requires a nurse for continuous care. Therefore, based on further review, the above allegation will be deemed Unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 2