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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601324
Report Date: 06/25/2026
Date Signed: 06/25/2026 02:02:09 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/17/2026 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20260617122050
FACILITY NAME:ELWYN NC - VISTAFACILITY NUMBER:
198601324
ADMINISTRATOR:HAZEL ANGELI GATANFACILITY TYPE:
734
ADDRESS:6034 N VISTA STTELEPHONE:
(626) 451-0550
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY:4CENSUS: 4DATE:
06/25/2026
UNANNOUNCEDTIME BEGAN:
12:22 PM
MET WITH:Andrea Lopez, LVNTIME COMPLETED:
01:55 PM
ALLEGATION(S):
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Facility did not maintain accurate records.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint visit to investigate the above allegation. The purpose of the visit was discussed with RN Sally Wu. Hazel Gatan was contacted telephonically.

The investigation consisted of: Record review was completed and a physical plant tour of the facility was completed. Staff (S1- S6) were interviewed. All residents are cognitvely impaired and were not interviewed. Resident (R1 & R2's) and staff (S1's) files were reviewed. Copies of documents were obtained. A copy of the Regional Center Corrective Action Plan (6/12/26) was obtained.

*See LIC9099C report narrative.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2026
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 28-AS-20260617122050
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ELWYN NC - VISTA
FACILITY NUMBER: 198601324
VISIT DATE: 06/25/2026
NARRATIVE
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Allegation: Facility did not maintain accurate records. The complaint alleges that on June 10, 2026, resident Medication Administration Records (MARs) were reviewed by Regional Center Quality Assurance Specialist, and a medication error was observed on resident (R1's) MAR. Medication Ergocalciferol Ergocalciferol 8,000 ML was not initialed by staff, but the medication was allegedly dispensed. In addition, during the Regional Center audit resident (R2's) Individual Health Care Plan (IHCP) was missing from the resident's file. The facility is an Adult Residential Facility for Persons with Special Health Care Needs (ARFPSHN) that serves medically fragile developmentally disabled residents that require 24/7 nursing support. A total of six (6) staff were interviewed. Resident (R1's) MAR medication error and R2's unavailable IHCP was confirmed by staff. 8:00 AM medications are typically given between 7:30 AM - 8:30 AM. Staff (S1) stated they administered the medication to R1, but forgot to initial the MAR and a 2nd staff forgot to check and initial the Medication Administration Verification form. The Medication Administration Verification form is to be signed by nursing staff and/or DSP staff. According to S1, they forgot to initial the MAR because they took 3 residents out for an outdoor walk after they got them ready following the 8 AM medication pass. During the visit, Medication Administration Records (MARs) were reviewed. No errors were observed. On June 12, 2026, the Regional Center issued a Corrective Action Plan (CAP). Therefore, based on document review and interviews there is sufficient evidence to corroborate the allegation.

Based on record review and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Pursuant to Title 22, California Code of Regulations, a deficiency is cited.

An exit interview conducted, copy of the report and appeal rights was provided to LVN Andrea Lopez.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20260617122050
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ELWYN NC - VISTA
FACILITY NUMBER: 198601324
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/02/2026
Section Cited
CCR
80070(a)
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Client Records. The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This requirement was not met evidenced by:
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Administrator agreed to submit:

1. Written Plan of Correction
2. Staff in-service training proof
3. A copy of R2's IHCP
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Based on record review and interviews, on 6/10/26 facility staff did not initial R1's Medication Administration Record (MAR); and a copy of R2's Individual Health Care Plan (IHCP) was not available for Regional Center (RC) audit review. RC issued a Corrective Action (CAP) plan. This poses a potential health, safety, and personal rights risks 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: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3