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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609743
Report Date: 10/11/2021
Date Signed: 10/11/2021 01:20:27 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
10/07/2021 and conducted by Evaluator Wendell Smith
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20211007122431
FACILITY NAME:ELWYN CALIFORNIA - QUARTZFACILITY NUMBER:
197609743
ADMINISTRATOR:JOSEPH TIGHEFACILITY TYPE:
737
ADDRESS:8033 QUARTZ AVETELEPHONE:
(925) 626-7014
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY:2CENSUS: 2DATE:
10/11/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Henry SessangaTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff do not have current first aid/CPR certifications.
First aid kit is incomplete.
Client's mattress is worn.
Facility is in disrepair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced complaint visit to investigate the allegations above. LPA met with facility staff and explained the reason for this visit. LPA spoke with administrator Joseph Tighe over the telephone regarding the visit.

Staff do not have current first aid/CPR certifications.
It is alleged that during a visit by North Los Angeles Regional Center (NLRC) on September 15-16th that a file review was conducted and that some facility staff first aid certificates had expired or that some staff did not have first aid training upon being hired. LPA spoke with the administrator regarding this allegation. Administrator stated that at the time of the visit that some of the staff first aid certificates had expired and some staff did not have them. Since then all of the staff have completed first aid training and the one staff who does not have a first aid certificate has been taken off of schedule until it is completed. LPA reviewed staff files from 10:00-10:20 am and observed all staff currently on schedule to have first aid certificates.
This allegation is deemed Substantiated. Deficiency cited on LIC 9099 D.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021
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-20211007122431
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 - QUARTZ
FACILITY NUMBER: 197609743
VISIT DATE: 10/11/2021
NARRATIVE
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First aid kit is incomplete.
It is alleged that during the visit by NLRC that the first aid kit was missing a thermometer. LPA spoke with the administrator regarding this and he stated it was missing but replaced right away. During the visit LPA checked the first aid kit at approximately 11am and observed the first aid kit to be complete. Based on the information obtained this allegation is deemed Substantiated. Deficiency cited on LIC 9099 D.

Client's mattress is worn.
It is alleged that during the visit by NLRC that client #1 (C1) mattress sunk inward and was not suitable for C1. An interview was conducted with the administrator that stated that a new bed has already been ordered for C1 due to how C1's bed was sunk in. Based on the information obtained this allegation is deemed Substantiated at this time.

Facility is in disrepair
It is alleged that on a visit by NLRC that the facility had some physical plant issues such as the side of the facility having trash scattered throughout the yard, facility windows being dirty, bathroom walls being dirty, rust stains in the shower, vent in the hallways being dusty, facility couches being broken, and tooth brushes being worn and without covers. Based on an interview with the administrator he admitted to all of those things happening but that they were fixed immediately. LPA conducted a physical plant walk through approximately from 9:10-9:30am. LPA observed all those items to be corrected. Based on the information obtained through this allegation is deemed Substantiated. Deficiency cited on LIC 9099 D. Appeal rights explained.
Exit Interview conducted.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20211007122431
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 - QUARTZ
FACILITY NUMBER: 197609743
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/11/2021
Section Cited
CCR
89965(k)(1)
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Personnel Requirements-Direct care staff shall maintain current certifications in first aid and cardiopulmonary resuscitation. The administrator shall maintain the certifications in the facility personnel records.
This requirement was not met as evidenced by:
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Corrected before visit. All staff have current first aid certificates.
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Based on interviews facility staff did not have current first aid certificates on file and some staff did not have any first aid certificates which could have posed a health and safety risk to clients in care.
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Type B
10/11/2021
Section Cited
CCR
80075(g)(1)(G)
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Health Related Services-If the facility has no medical unit on the grounds, first aid supplies shall be maintained and be readily available in a central location in the facility and should include a thermometer.
This requirement was not met as evidenced by:
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Corrected before visit. The thermometer was placed in the first aid kit.
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Based on interviews conducted the first aid kit was missing a thermometer for a time. This posed a potential health and safety risk to the 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: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20211007122431
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 - QUARTZ
FACILITY NUMBER: 197609743
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/11/2021
Section Cited
CCR
80072(a)(2)
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Personal Requirements-To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
This requirement was not met as evidenced by:
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Corrected before visit. C1 had a new mattress ordered.
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Based on interviews conducted C1 mattress was not in good condition which posed a potential health and safety risk to C1.
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Type B
10/11/2021
Section Cited
CCR
80087(a)
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Buildings and Grounds-The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
This requirement was not met as evidenced by:
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Corrected before visit. Physical plant issues were corrected before visit. LPA observed the corrections.
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Based on interviews conducted there were numerous physical plant issues such as items being dirty and worn down in the facility which posed a potential health and safety risk to 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: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4