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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609010
Report Date: 05/07/2025
Date Signed: 05/07/2025 02:28:06 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
05/05/2025 and conducted by Evaluator Michael Cava
COMPLAINT CONTROL NUMBER: 31-AS-20250505121534
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:
05/07/2025
UNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Yvette Cosme, Gerlie MiguelTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff did not keep medication in a safe locked place that is not accessible to clients
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 the administrator, Yvette Cosme, and staff, Gerlie Miguel, and advised them of the complaint. Today's investigation consisted of interviews with staff and residents, a physical plant inspection, and record review.

Regarding the allegation, it was alleged that medications are being left out in open/common areas of the facility where clients can reach and have access to the medicine. These areas include the kitchen counter and open areas of the client bedrooms. It was also reported that keys to the medication cart is left on top of the cart, exposed and accessible to anybody, including clients in care. Information received from a direct source confirm that on 04/14/25, 04/22/25 and 04/30/25, medications and keys to the medication cart were left out and accessible to anybody, including clients in care. During investigation on this date, while conducting a physical plant inspection, LPA observed keys to the medication cart, on top of the medication
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025
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 5
Control Number 31-AS-20250505121534
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: 05/07/2025
NARRATIVE
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cart, accessible to anyone, including the clients in care.

Based on the information obtained, there is sufficient evidence to confirm that staff do not keep medications in a safe or locked place that is not accessible to clients. Therefore, the allegation is Substantiated. Citation issued on the 9099D. Administrator advised, and a copy of this report issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20250505121534
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: 05/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/07/2025
Section Cited
CCR
80075(k)(1)
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Health Related Services- Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by: Information received that medication and/or
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As POC, the administrator will provide in service training to address this section of the regulation. As proof training was held, a copy of the training log, attendance sheet, training topic and name of the instructor will be submitted to the Licensing Agency by May 21, 2025.
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keys to the medication cart was accessible to clients on 04/14/25, 04/22/25 and 04/30/25. Moreover, during investigation on 05/07/25, LPA observed the keys to the medication cart, on top of the cart, making it accessible to anyone, including clients, which pose an immediate H&S risk clients 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: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
05/05/2025 and conducted by Evaluator Michael Cava
COMPLAINT CONTROL NUMBER: 31-AS-20250505121534

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:
05/07/2025
UNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Yvette Cosme, Gerlie MiguelTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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9
Staff are fulfilling duties that they are not trained for
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 the administrator, Yvette Cosme, and staff, Gerlie Miguel, and advised them of the complaint. Today's investigation consisted of interviews with staff and residents, a physical plant inspection, and record review.

Regarding the allegation, it was reported that non Direct Support Profession (DSP), DSP 1 and DSP 2 staff, are helping to prepare, administer, and document medication record. DSP staff are trained staff to help assist in these duties. Prior to the day's inspection, LPA conducted a file review of the facility's policy statement in administering medications, which indicate under "Policy Interpretation and Implementation (pg 1, #4)- only persons licensed/trained DSP may prepare, administer and document the administratration of medications". During the day's investigation, LPA conducted a file review of three (3) staff files, and observed staff title, training, duties and qualification to their position. Interviews with three (3) of three
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20250505121534
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: 05/07/2025
NARRATIVE
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of three staff also confirm their position.

Based on the information obtained, there was insufficient evidence to corroborate the allegation of staff are fulfilling duties that they are not trained for. Therefore, the allegation is deemed Unsubstantiated at this time. Administrator advised, and a copy of this report issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5