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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609743
Report Date: 08/07/2024
Date Signed: 08/07/2024 03:12:54 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
08/02/2024 and conducted by Evaluator Perchui Khurshudyan
COMPLAINT CONTROL NUMBER: 31-AS-20240802091051
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:
08/07/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Stephen Wamala, Administrator TIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff mismanaged resident's medications.
INVESTIGATION FINDINGS:
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On 8/7/2024 at 12:00pm, Licensing Program Analysts (LPAs) Perchui Milena Khurshudyan and Angela Panushkina conducted an unannounced, initial 10-day visit to investigate the above allegation. Upon arrival, LPAs met with the Administrator and explained the reason for the visit.

During a physical plant tour at 11:10am, LPAs observed that the house is generally clean and organized.
At 11:20am LPAs requested and reviewed client files and obtained copies of pertinent documents which include, but not limited to Admission Agreement, Physician Reports, Individual Program Plan (IPP), Centrally Stored Medications and Destruction Records (CSMDR), and Medication Administration Record (MAR).

It was reported that on 07/11/24, a credible witness conducted an unanounced visit to the facility and observed that staff mismanaged C1's medications. During today's visit, LPAs conducted review of C1's

Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024
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 3
Control Number 31-AS-20240802091051
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ELWYN CALIFORNIA - QUARTZ
FACILITY NUMBER: 197609743
VISIT DATE: 08/07/2024
NARRATIVE
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CSMDR and MAR and detected and identified that C1 hasn’t been administered the Topical Cream for the period of 7/1/24-7/15/2024, due to not having the medication refilled on time by the facility staff. LPAs conducted an interview with the facility Administrator, who confirmed that the medication refill request was placed on 07/01/24 through the pharmacy. However, per pharmacy’s request the facility staff was supposed to contact C1’s Primary Care Physician (PCP) for a new authorization/order. Administrator also confirmed that due to miscommunication/misunderstanding no one from the facility contacted PCP for C1’s ointment until 07/15/24. The information obtained during the interview confirmed the allegation and statements were made that the Staff mismanaged client’s medications. The Allegation is Substantiated.

Exit interview conducted, Deficiency issued on LIC9099-D

Copy of appeal rights and report delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20240802091051
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELWYN CALIFORNIA - QUARTZ
FACILITY NUMBER: 197609743
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/14/2024
Section Cited
CCR
80075(5)(A)
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Health Related Services (5)If the client's physician has stated in writing… (A) There is a written direction from a physician… instructions regarding a time or circumstance (if any) when it should be discontinued...
This requirement is not met as evidenced by:
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Licensee/Administrator will provide all staff training, on 08/08/24, regarding this regulation and submit certificated to LPA
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Based on interviews the licensee did not comply with the section cited above by not administering C1’s prescribed ointment due to not receiving it on time. This poses/posed a potential health and safety risk to persons 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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024
LIC9099 (FAS) - (06/04)
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