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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609010
Report Date: 08/01/2022
Date Signed: 08/01/2022 01:02:51 PM

Document Has Been Signed on 08/01/2022 01:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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 - INDEXFACILITY NUMBER:
197609010
ADMINISTRATOR:VELARDE, EDWARDFACILITY TYPE:
735
ADDRESS:17328 INDEX STTELEPHONE:
(626) 500-1430
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 4CENSUS: 4DATE:
08/01/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Tayo Labeodan /AdministratorTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility in response to an incident report received on 7/21/22. LPA was greeted by facility staff and had his temperature taken and Covid 19 questions asked before being allowed entry.

The incident in question was related to an incident of abuse from a staff on a facility resident (R1). The LPA was able to speak with staff who were present during the day of the alleged incident. Both staff interviewed, denied seeing or hearing any yelling or calls for help. A body check of the resident in question did not result in any signs of bruising or red marks on the clients skin. The resident in question was interviewed and appeared to be repeating things the LPA was asking. A review of R1's paperwork indicated that R1 has a history of delusions and staff are working with R1 to differentiate fantasy from fiction.

The facility is currently investigating this allegation, as this was a self reported incident. An investigator from their corporate office has initiated their internal investigation. The staff member in question has been removed from the facility and will not return until their findings have been determined. The facility administrator has agreed to share the findings, once their investigation has been completed.

Exit interview conducted and report issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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