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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609010
Report Date: 09/23/2022
Date Signed: 09/23/2022 02:07:53 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
09/14/2022 and conducted by Evaluator Patrick Shanahan
COMPLAINT CONTROL NUMBER: 31-AS-20220914163527
FACILITY NAME:ELWYN CALIFORNIA - INDEXFACILITY NUMBER:
197609010
ADMINISTRATOR:TAYO LABEODANFACILITY TYPE:
735
ADDRESS:17328 INDEX STTELEPHONE:
(626) 500-1430
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:4CENSUS: 4DATE:
09/23/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Tayo LabeodanTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Facility did not ensure that staff had the required training/certification(s) while working at the facility.
Facility did not ensure that staff with specialized skills/license were at the facility when required.
Staff falsified resident(s) MAR.
Staff did not administer medication(s) to resident as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility and was greeted by facility staff. The administrator was called and arrived a short while later. LPA explained the reason for the visit.
Allegation 1. Facility did not ensure that staff had the required training/certification(s) while working at the facility.

LPA was able to interview the administrator regarding this allegation. The administrator stated that his facility recently had an annual inspection from Regional Center. During the review, one staff member was observed to not have an updated first aide certificate. The administrator confirmed that all of the staff have had all of their training updated and supplied the LPA with the facilities corrective action plan indicating that the first aide certification has been completed. This allegation is deemed substantiated based on the administrators confirmation and a review of the regional center annual.

Continues on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
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 4
Control Number 31-AS-20220914163527
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 - INDEX
FACILITY NUMBER: 197609010
VISIT DATE: 09/23/2022
NARRATIVE
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Allegation 2. Facility did not ensure that staff had the required training/certification(s) while working at the facility.
The LPA was able to interview the staff in question and the administrator regarding this allegation. Staff interviewed confirmed that on 8/13/22, she had a family emergency. During this time there was no LVN coverage for the home. The administrator stated that he did receive a call from the staff and was notified of the emergency and that the staff would need to leave early. Staff left the home at about 3pm but there was no LVN coverage until about 4pm. The PM shif LVN was notified and arrived at the home early. The program design outlines that there will be coverage 24 hours a day, but in this case there was no coverage available. Based on interviews with LVN staff and confirmation from the administrator, this allegation is deemed Substantiated.

Allegation 3. Staff falsified resident(s) MAR.
LPA was able to speak with the facility administrator and the LVN staff who was noted in this allegation. The LVN was interviewed at about 9:45AM, and confirmed that on 8/13/22 she had a family emergency and needed to leave the facility early. The LVN states that she was able to give the medications to 3 out of the 4 residents at the home, but would not be at the home to give the 4pm medication to the resident in question (R1). The LVN then stated that she prepared the meds and placed them in the locked medicine cabinet for another staff to give them to the resident while she was out. The LVN signed the MARS, indicating that the medications had been given out, however R1 never received the 4PM medications. The administrator also confirmed that this incident occurred and that he has held an in-service and medication training for all staff. Based on confirmation from the facility LVN and Administrator, this allegation is deemed Substantiated.

Allegation 4. Staff did not administer medication(s) to resident as prescribed
LPA was able to speak with the facility administrator and the LVN staff who was noted in this allegation. The LVN was interviewed at about 9:45AM, and confirmed that on 8/13/22 she had a family emergency and needed to leave the facility early. The LVN states that she was able to give the medications to 3 out of the 4 residents at the home, but would not be at the home to give the 4pm medication to the resident in question (R1). The LVN had prepared the medications for R1, however they were not given. The administrator confirmed that this incident had occurred and that R1 was experiencing a behavior episode. A special incident report was sent to Licensing, R1's doctor and R1's responsible party. Based on confirmation from the facility LVN and the Administrator, this allegation is deemed to be substantiated at this time.
Exit Interview conducted, deficiencies cited and report issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20220914163527
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 - INDEX
FACILITY NUMBER: 197609010
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/23/2022
Section Cited
HSC
1569.58(a)2
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H&S1569.58(a)2- Conduct Inimical Conduct which is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California. This requirement is not met as evidenced by: Based on confirmation from staff and the
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Corrected before visit.
Administrator conducted medication training for all staff at the facility
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Administrator, the licensee did not ensure the medication log was filled out correctly and indicated medications had been given when they weren't, which poses an immediate health and safety risk to the residents in care.
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Type B
09/23/2022
Section Cited
CCR
80075(f)
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80075(f) Health Related Services. Staff providing care and supervision shall receive first aid training from qualified agencies including but not limited to the American Red Cross. This requirement is not met as evidenced by; based on administrator confirmation, 1 staff was observed to have
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.Cleated before visit.
Administrator provided proof that the certification for the staff has been renewed.
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an expired first aide certificate, which poses a potential risk to the residents in care
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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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20220914163527
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 - INDEX
FACILITY NUMBER: 197609010
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/23/2022
Section Cited
CCR
80075(b)5(B)
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80075(b)(5)(B) Health Related Services. Medications shall be given according to physician's directions. This requirement is not met as evidenced by the review of the documents and interviews. Based on interviews with the LVN and administrator, R1's medication was not given as
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Cleared before visit
Administrator held an in-service for all staff on medications.
Documents provided to LPA as POC
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Prescribed which poses a potential risk to the health and safety of residents in care.
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Type B
09/23/2022
Section Cited
CCR
80072(a)(1)
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80072(a)(2) Personal Right
(a) Except for children's residential facilities, each client shall have personal rights which include, but are not limited to the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

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Cleared before visit
The administrator confirmed that a new LVN has been hired and that there is a staff member on call 24 hours a day.
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Based on interviews with the LVN and the facility administrator, the Licensee failed to have an LVN on duty, which posed apotentional risk to the health and safety of the residents in care.
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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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4