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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609009
Report Date: 10/20/2022
Date Signed: 10/20/2022 02:22:02 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
10/05/2022 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20221005154823
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:
10/20/2022
UNANNOUNCEDTIME BEGAN:
08:23 AM
MET WITH:Tayo Labeodan - AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff handled resident in a rough manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gary Tan conducted unannounced initial complaint visit at this facility to investigate the above allegation. LPA met with administrator Tayo Labeodan and explained the reason for the visit.

LPA conducted physical plant tour at 8:45 AM, requested copies of facility documents relevant to the investigation and interviewed additional staff between 9:45 to 11:20 AM.

It was alleged that Staff #1 (S1) handled Resident #1 (R1) roughly when S1 was changing R1's clothes. LPA's interview with Staff #2 (S2) today at 9:40 AM who was at the facility during the time of the incident revealed that on 09/30/22 at around 2:20 PM, R1 was refusing to get dressed after shower as R1 always do. R1's refusal was heard by other staff which prompted other staff to come in the bathroom.

(continued on LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
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-20221005154823
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: 10/20/2022
NARRATIVE
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(continued from LIC 9099)

Staff #3 (S3) came in the bathroom and conflict ensued between S1 and S3, S2 saw S1 left R1 still undressed due to the conflict. S3 dressed R1 as S1 left the facility. Further interview with S2 also revealed that S2 did not witness S1 forcing or insisting R1 to get dressed as S2 saw R1 was still undressed when S1 left.. LPA's phone interview with S1 today at 1:11 PM also revealed that S1 did not coerce nor insist on dressing R1. S1 denied rough handling R1 in any way.

Based on the information gathered during this and prior visit. the allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2