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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609009
Report Date: 08/07/2024
Date Signed: 08/07/2024 02:15:37 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
08/01/2024 and conducted by Evaluator Michael Cava
COMPLAINT CONTROL NUMBER: 31-AS-20240801094701
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:
08/07/2024
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Aurora CruzTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff left resident unattended resulting resident falling sustaining an injury.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to the facility to investigate the above allegation. LPA met with staff, Aurora Cruz, and advised her of the complaint. The administrator, Yvette Cosme, was notified over the telephone shortly after. It was reported that on or around 07/30/24, during swing shift between 2:00pm-10:00pm Residet 1 (R1) was left unattended by staff and fell. It is unknown why R1 was left unattended. R1 was reported to have sustained a bruise at the upper left back. R1 wasn't taken to the emergency room or urgent care until another staff suggested for R1 to get transported. Furthernore, R1 does require one to one supervision, and cannot be left unattended at any time. Today's investigation consisted of interviews with the administrator, staff, and residents.

Prior to the investigation, LPA Cava conducted a file review and reviewed an Incident Report (IR) that was submitted by the facility on 07/31/24. The report indicated that R1 was sent to urgent care due to a bruise being observed. IR also indicated that the cause of injury was unknown. R1 stated they fell,
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024
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 2
Control Number 31-AS-20240801094701
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: 08/07/2024
NARRATIVE
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but there were no reports or documentation from attending staff recorded that R1 had a fall.

Interviews made with the administrator deny the allegation. Administrator confirmed that R1 requires a one to one staff, and needs to be within arms length of R1 at all times. Internal investigation made, and staff on duty on those dates, R1 was never left unattended. Interviews with four (4) of four staff also deny the allegation. Staff indicated that if they need to go on break, a supervisor gets notified for coverage, and that staff cannot leave R1's side until there is coverage. In regards to R1, staff adds that R1 has a history of skin breakdown, and has a tendency to on their skin, and bruising can occur.

Review of facility records confirm that R1 does require on going 1 to 1 supervision. Daily progress notes for 07/30/24 and 07/31/24 reveal no documentation of any falls. R1's assessments also reveal that R1 has skin lesions.

Based on the information obtained, there wasn't enough evidence to prove that R1's injury was due to the absence of staff, or R1 being unattended by staff. Therefore, the allegation is deemed Unsubstantiated at this time.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2