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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609743
Report Date: 09/11/2023
Date Signed: 09/11/2023 03:34:48 PM

Unsubstantiated


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
04/19/2023 and conducted by Evaluator Tihesha Smith
COMPLAINT CONTROL NUMBER: 31-AS-20230419135106
FACILITY NAME:ELWYN CALIFORNIA - QUARTZFACILITY NUMBER:
197609743
ADMINISTRATOR:STEPHEN WAMALAFACILITY TYPE:
737
ADDRESS:8033 QUARTZ AVETELEPHONE:
(925) 626-7014
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY:2CENSUS: 2DATE:
09/11/2023
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Stephen WamalaTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Facility is utilizing expired hand sanitizer
Facility is not following residents IPP plans
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Tihesha Smith made a subsequent unannounced complaint visit to the facility on 09/11/2023 and met with facility staff and explained the purpose of this visit. The administrator was present at the facility.
On 07/11/2023, LPA Smith made a subsequent visit to deliver findings. During initial visit, on 04/20/2023, LPA Smith conducted tour of physical plant at 2:40 pm, conducted interview with the administrator and requested documents relevant to the investigation at 3:18 pm.

Facility is utilizing expired hand sanitizer

During the physical plant tour on 04/20/2023 LPA observed a bottle of with hand sanitizer near sign-in log with an expired date. However, interview with the administrator revealed the hand sanitizer is purchase in bulk containers and the empty bottles with expired dates are refilled. Administrator also states have purchase order/receipt for hand sanitizer that was ordered March 20,2023.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023
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-20230419135106
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: 09/11/2023
NARRATIVE
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(Cont from 9099)

LPA Smith reviewed the bulk bottles which have an expiration date of 02/2027.
Based interview, observation, and review of records although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Facility is not following residents IPP Plans

Interview with administrator on 09/11/2023 revealed that two (2) out of (2) residents have IPPs, and he ensure that all staff are following the plans. Administrator revealed the IPPs do not include a breakdown or information about consults with Dietician, Registered Nurse, Recreational therapy and or Psychiatric pharmacotherapy hours. LPA Smith reviewed the IPP for two (2) out of two (2) residents and each plan did not mention consultation hours with Dietician, Registered Nurse, Recreational therapy and or Psychiatric pharmacotherapy.

Based interview and record review, although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
04/19/2023 and conducted by Evaluator Tihesha Smith
COMPLAINT CONTROL NUMBER: 31-AS-20230419135106

FACILITY NAME:ELWYN CALIFORNIA - QUARTZFACILITY NUMBER:
197609743
ADMINISTRATOR:STEPHEN WAMALAFACILITY TYPE:
737
ADDRESS:8033 QUARTZ AVETELEPHONE:
(925) 626-7014
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY:2CENSUS: 2DATE:
09/11/2023
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Stephen WamalaTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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2
3
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5
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7
8
9
Facility is storing incomplete files for residents
INVESTIGATION FINDINGS:
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Facility is storing incomplete files for residents

LPA Smith review of two (2) out of two (2) resident files to include but not limited to: Physician report and Individual Program Plans (IPPs) on 09/11/2023 revealed that entries on physician report incomplete and or missing dates, signatures, entries. TB testing for two (2) out of two (2) residents are missing. Interview with administrator revealed test for residents not completed. Administrator also revealed a chest x-ray was performed for Resident One (R1) but administrator need to verify if test was for TB screening.
Based on record review and interview there is sufficient evidence to prove the alleged violation did occur. Therefore, the allegation is deemed SUBSTANTIATED at this time.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20230419135106
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: 09/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/11/2023
Section Cited
CCR
80070(a)
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(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.
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The administrator will schedule ensure records are complete and all entries completed. Administrator will also schedule dates for TB testing and send date to LPA Smith. POC due date: 10/11/2023
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This requirement was not met based on: License did not ensure client physcians report were complete and TB testing performed and noted in records. This poses a potential risks for 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: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4