197609009-5-23-2024-31-AS-EMIR-D8XVQP-20240909163841

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609009
Report Date: 05/23/2024
Date Signed: 05/23/2024 02:19:06 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
05/21/2024 and conducted by Evaluator Michael Cava

COMPLAINT CONTROL NUMBER: 31-AS-20240521151323

FACILITY NAME:	ELWYN CALIFORNIA - YARMOUTH		FACILITY NUMBER:	197609009
ADMINISTRATOR:	TAYO LABEODAN		FACILITY TYPE:	735
ADDRESS:	10512 YARMOUTH AVE		TELEPHONE:	(818) 488-1753
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	4	CENSUS: 4	DATE:	05/23/2024
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Yvette Cosme		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff did not dispense resident’s medication as prescribed.
Staff did not ensure accurate resident files were maintained.
Staff did not report incident involving resident as required.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michael Cava conducted a complaint vist to the facility to investigate the above allegations. LPA met with the administrator, Yvette Cosme, and advised her of the allegations. Today's investigation consisted of interviews, record review and a physical plant inspection.

Staff did not dispense resident's medication as prescribed:
In regards to the allegation, it was reported that on or around 02/24/24, Resident 1 (R1) was not given Quetiapine for their 5pm medication. LPA reveiwed R1's medcation current and past medication records. Review of the Medication Administration Records (MAR) show that R1 was administered their Quetiapine at 7am and at 5pm on 02/24/24. In conjunction with this complaint, LPA Cava conducted a Required Annual inspection, which included medication review. A review of all four resident MARs show consistency and no discrepancy when medications are administered. Staff were also interviewed with medication procedures and documentation. R1 could not recall if meds were missed or taken on or around 02/24/24. Based on the

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20240521151323

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: 05/23/2024

NARRATIVE

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information obtained, it could not be proven that staff did not dispense R1's medication as prescribed. Therefore, the allegation is deemed Unsubstantiated at this time.

Staff did not ensure resident files were maintained:
In regards to the allegation, it was reported that an incident report for an incident, that had occurred on or around 02/24/24, regarding R1's medication was misfiled. It should have been reported that, on or around 02/24/24, R1's Quetiapine was not administered as prescribed by their physician. In reviewing R1's MAR, R1 never missed taking this medication, which would have warrant the facility to submit one if R1 did. Interview with the administrator, confirmed R1 did not miss their medication on that date, and that R1 is usually compliant with taking their medication. R1 could not recall whether or not medications were taken or missed on or around 02/24/24. Based on the information obtained, there was insufficient evidence to prove staff not ensuring files are maintained. Therefore, the allegation is deemed Unsubstantiated at this time.

Staff did not report incident involving resident as required:
In regards to the allegation, it was reported that the licensee failed to submit incident reports involving R1. The first incident that the facility failed to report was their missed medication, which occurred on or around 02/24/24. The second incident report that the licensee should have reported was a personal rights incident involving R1, that occurred sometime on or around January or February of 2024. Regarding the first incident, that was alleged to have occurred on or around 02/24/24, LPA conducted interviews and record review, and there was no evidence that R1 missed taking their medication on 02/24/24. In regards to the second incident, LPA conducted a file review of the facility files and incident reports, that is logged into the Regional Office (RO) server electronically. LPA observed that there was a Serious Incident Report (SIR), reported and reviewed on 01/18/24, pertaining to R1's personal rights, which satisfies the licensees responsibility of reporting requirements. Based on the information obtained, there was insufficient evidence to prove that staff did not report incident involving R1 as required. Therefore, the allegation is deemed Unsubstantiated at this time.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC9099 (FAS) - (06/04)

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