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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609010
Report Date: 05/13/2025
Date Signed: 05/13/2025 02:33:59 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
05/09/2025 and conducted by Evaluator Michael Cava
COMPLAINT CONTROL NUMBER: 31-AS-20250509152334
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:
05/13/2025
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Yvette CosmeTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff are not following phisician's order
Staff are not documenting the MAR properly
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, Yvette Cosme, and advised her of the complaint. According to information received from a direct source, Resident 1's (R1) medication was administered approximately 2.5 hours earlier than the prescribed administration time of 10:00 a.m. A review of the Medication Administration Record (MAR) revealed that the 10:00 a.m. medication had already been signed off and documented as administered, despite the medication not having been given at that time. Additionally, a review of the controlled medication log for on or around May 1, 2025 revealed that medication for Resident 2 (R2) had been pre-signed for all three shifts in the morning, afternoon, and night. Although LPA Cava conducted a record review of medication records for the day, and did not observe any discrepancies or signatures indicating the medicaitons had already been administered, based on the information obtained, and a Correction Action Plan (CAP) that was issued, the above allegations are Substantiated. Citations issued on the 9099D. Administrator advised and a copy of this report issued.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
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 2
Control Number 31-AS-20250509152334
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: 05/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/13/2025
Section Cited
CCR
80075(b)
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Health Related Services: Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met as evidenced by, information received reveal that R1 was administered their medication at least 2.5 hours before prescribed.
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Licensee was issued a Corrective Action Plan (CAP) due June 7, 2025. As POC, copy of this CAP is also due to the Licensing agency by June 7, 2025
Type A
05/13/2025
Section Cited
CCR
80075(k)(7)
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Health Related Services: The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications. This requirement was not met as evidenced by, on or around May 1, 2025 revealed that medication for Resident 2 (R2) had been pre-signed for all three shifts
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Licensee was issued a Corrective Action Plan (CAP) due June 7, 2025. As POC, copy of this CAP is also due to the Licensing agency by June 7, 2025
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in the morning, afternoon, and night.
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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: 05/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2