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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609009
Report Date: 07/19/2024
Date Signed: 07/19/2024 01:55:01 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:
07/19/2024
UNANNOUNCEDTIME BEGAN:
08:38 AM
MET WITH:Yvette CosmeTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility is not adhering to resident's Admission Agreement.
Staff are not providing care to resident(s) as necessary to meet resident(s) needs while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to the facility to investigate the above allegations. LPA met with the administrator, Yvete Cosme, and advised her of the complaint. Today's investigation consisted of interviews with staff and residents, record review, and a physical plant inspection.

Facility is not adhering to resident's admission agreement:
In regards to the allegation, it was reported that the facility didn't 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 Regional Center (RC) was received, which reveal 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. Based on this information received, the facility failed to provide services and coverage on 06/08/24, from 9pm to 7am. Therefore, the allegation is Substantiated. Citation issued on the 9099D, and copy of this report issued.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
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 3
Control Number 31-AS-20240716123550
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: 07/19/2024
NARRATIVE
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Staff are not providing care to resident(s) as necessary to meet resident(s) needs while in care:
In regards to the allegation, it was reported that the facility didn't have a required staff, or nurse, on shift, on 06/08/24 and 06/14/24. Reports received reveal that Resident 1 (R1), had seizures on those dates. According to R1's Admission Agreement, and the facility's program's description, the facility will maintain a nurse on shift 24 hours every day to meet the needs of the residents in care. As a result of the nurse's absence, staff did not provide care to R1 as necessary to meet R1's needs when they experienced seizures on 06/08/24 and 06/14/24. Based on the information received from the Regional Center, the allegation is Substantiated. Citation issued on the 9099D, and copy of this report issued
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20240716123550
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: 07/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/19/2024
Section Cited
CCR
80078(a)
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Responsibility for Providing Care and Supervision: The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by the lack of the facility to adhere to their program description and the resident's admission agreement. According
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The facility was issued Corrective Action Plan (CAP) from the Regional Center to be completed by 08/15/24. Licensee will submit a copy of this CAP to the licensing agency once completed
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to both, "an LVN remains on duty until relieved by incoming staff". it was reported that the facility didn't have a required nurse on shift, on 06/08/24 and 06/14/24. This posed an immediate health and safety risk to the resident in care.
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Type A
07/19/2024
Section Cited
CCR
80065(a)
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Personnel Requirements: Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. This requirement was not met as evidenced by confirmation that on 06/08/24 and 06/14/24
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The facility was issued Corrective Action Plan (CAP) from the Regional Center to be completed by 08/15/24. Licensee will submit a copy of this CAP to the licensing agency once completed
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facility didn't have a nurse on shift. R1's Admission Agreement and the facility's program description indicate the facility will maintain a nurse on shift 24 hours per day to meet resident needs. As a result of a nurse's absense, no staff was available to meet R1's needs when they experienced a seizure.
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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: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3