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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601324
Report Date: 07/23/2026
Date Signed: 07/23/2026 09:28:04 AM

Document Has Been Signed on 07/23/2026 09:28 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ELWYN NC - VISTAFACILITY NUMBER:
198601324
ADMINISTRATOR/
DIRECTOR:		HAZEL ANGELI GATANFACILITY TYPE:
734
ADDRESS:6034 N VISTA STTELEPHONE:
(626) 451-0550
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY: 4CENSUS: 4DATE:
07/23/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Linda Loeung, Registered NurseTIME VISIT/
INSPECTION COMPLETED:
09:35 AM
NARRATIVE
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Licensing Program Analyst (LPA) Daniel Konishi conducted a case management visit per follow-up on Special Incident Reports (SIRs) dated 7/14/2026 submitted to the department on 7/14/2026. LPA met with the RN (Registered Nurse), Linda Loeung and LPA explained the purpose of the visit. LPA Konishi spoke with the Administrator, Hazel Gatan over phone and LPA explained the purpose of the visit.

It was revealed on the Special Incident Report (SIR) dated 7/14/2026 that on 7/3/2026, Client #1 (C1) was given Metoprolol Tartrate 25mg tab and the medication order includes a parameter to hold the medication if C1’s heart rate is below 60 beats per minute. On 7/3/2026, C1’s heart rate was documented as 48 beats per minute prior to administration. It is also revealed on the SIR dated 7/14/2026 that on 7/5/2026, Client #2 (C2) was given Midodrine HCL 10mg tab and the medication order includes a parameter to hold the medication if C2’s Systolic Blood Pressure (SBP) is greater than 110. On 7/5/2026, the C2l’s SBP was 118 prior to administration. LPA interviewed the Administrator over the phone and the Administrator confirmed stating that the medication errors occurred.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed are indicated on the LIC809-D page.

Exit interview held, appeal rights, and a copy of the report were provided to the RN, Linda Loeung.

David Sicairos
Daniel Konishi
DATE: 07/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2026
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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Document Has Been Signed on 07/23/2026 09:28 AM - It Cannot Be Edited


Created By: Daniel Konishi On 07/23/2026 at 09:06 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/23/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/24/2026
Section Cited
CCR
80075(b)

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(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
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Administrator will submit a written plan by POC due date indicating when they will retrain staff regarding passing of medication. Administrator will submit retrain training materials and sign in sheet to the LPA by 08/06/2026.
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By record review and interview, the facility had two (2) medication errors that occurred. Based on LPA interviewing the Administrator during the visit and it was also revealed on a Special Incident Report (SIR) dated 7/14/2026 that on 7/3/2026, Client #1 (C1) was given Metoprolol Tartrate 25mg tab and the medication order includes a parameter to hold the medication if C1’s heart rate is below 60 beats per minute. On 7/3/2026, C1’s heart rate was documented as 48 beats per minute prior to administration. Based on LPA interviewing the Administrator during the visit and it is also revealed on another SIR dated 7/14/2026 that on 7/5/2026, Client #2 (C2) was given Midodrine HCL 10mg tab and the medication order includes a parameter to hold the medication if C2’s Systolic Blood Pressure (SBP) is greater than 110. On 7/5/2026, the C2l’s SBP was 118 prior to administration. This poses an immediate health, safety or personal rights 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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2026


LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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