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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609009
Report Date: 09/19/2022
Date Signed: 09/19/2022 12:27:30 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
09/14/2022 and conducted by Evaluator Patrick Shanahan
COMPLAINT CONTROL NUMBER: 31-AS-20220914171606
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: DATE:
09/19/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Tayo Labeodan/ AdministratorTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Facility did not ensure that staff with specialized skills/license were at the facility when required.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the home and was greeted by the facility staff. LPA explained the reason for the visit and the administrator was called. The administrator arrived a short while later.
Allegation 1. Facility did not ensure that staff with specialized skills/license were at the facility when required.
LPA was able to interview the facility administrator and review the facility program design in order to come to findings for this allegation. The administrator stated that at the time of the incident, the facility was always within its staffing ratio. A resident had a medical appointment and one staff and the facility LVN went with the resident to the appointment. At the home there were two additional staff an 3 residents. The Program Design states that the resident shall have a ratio of 1 to 2 or 2 to 4, which the facility was in compliance with.
Continues on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022
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-20220914171606
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
VISIT DATE: 09/19/2022
NARRATIVE
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The Program Design indicates that a lead staff plus 3 Direct Support Staff (DSP) will be scheduled throughout the 24 hour day. A review of the staffing schedule indicated that their were 3 DSP scheduled and one LVN/ lead staff scheduled for the day in question. The facility also has a contingency plan in the Program Design for emergencies and specific staff are placed on call 24 hours a day so that the ratios will be met.

Based on information received from interviews with the facility administrator and through a review of the program design, this allegation is deemed UNSUBSTANTIATED.

Exit interview conducted and report issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2