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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601509
Report Date: 06/29/2022
Date Signed: 06/29/2022 05:07:53 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
04/22/2022 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220422123536
FACILITY NAME:ELWYN NC - DE SALESFACILITY NUMBER:
198601509
ADMINISTRATOR:EDWARD VELARDEFACILITY TYPE:
735
ADDRESS:610 N DE SALES STTELEPHONE:
(626) 872-6983
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY:4CENSUS: 4DATE:
06/29/2022
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Hazel Gatan, AdministratorTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff are not supervising residents adequately.
Client was able to leave the facility without staff supervision.
Facility gate is in disrepair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint to deliver findings on the above allegations. The purpose of the visit was discussed with Administrator Hazel Gatan.

The investigation consisted of: On 4/27/22 & today an inspection of the interior and exterior physical plant was conducted. Staff (S1-S4), (2) neighbor interviews, and Eastern Los Angeles Regional Center Service Coordinator were interviewed. Clients are non-verbal and were not interviewed. Auditory alarms on exit doors were observed. LPA obtained the following documents: LIC 500 Personnel Report, resident roster, and client (C1's) file documents [IPP, Face Sheet, Physician Report. On 4/20/2022, the Eastern Los Angeles Regional Center issued a Corrective Action Plan (CAP) as a result of inadequacies found during visits pertaining to C1 and C2's health and safety. The Regional Center issued a Substantial Inadequacy as per Title17 California Code of Regulations 56054(a)(1) "of conditions posing a threat to the health and safety of any consumer."

See LIC 9099C for report continuation.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022
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 28-AS-20220422123536
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 - DE SALES
FACILITY NUMBER: 198601509
VISIT DATE: 06/29/2022
NARRATIVE
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Allegation: "Staff are not supervising residents adequately." Based on interviews conducted the findings indicate that at on at least three (3) occasions during a course of 3 weeks in April 2022, client (C1) has been observed unsupervised in the front yard and sidewalk area. The facility driveway gate was in disrepair and it is alleged C1 was able to walk out the driveway without staff supervision. Staff stated that client (C1) is typically supervised when it goes outdoors, but due to the broken gate in the driveway C1 walked to the front yard area. Staff stated that when that occurs staff immediately go redirect the client. However, neighbor interviews revealed that C1 has walked out to the front yard, and staff are not always seen near the client. In addition, on April 26, 2022 neighbors observed C1 alone in the sidewalk. A few minutes later a male staff was seen redirecting C1 back to the facility. Client (C1) paces and walks around the yard throughout the day. Administrator stated that on April 13, 2022 a plumber was at the facility and may have left the driveway gate opened. However, per IPP C1 is not to be left unsupervised.

Allegation: Client was able to leave the facility without staff supervision. Based on interviews conducted on April 13, 2022, client (C1) exited the facility through the dining room French doors and walked out through the driveway to the front yard. A plumber that was completing repairs at the facility notified staff (S1) that the client was in the unfenced front yard grass area unsupervised. It is unknown of C1 exited the facility through the side door that did not have an auditory alarm because it was moved to the bathroom in order to mitigate another client's behavior. Or if C1 exited through the dining room French doors that did have a working auditory alarm. Staff (S1) stated that the alarm chime was not heard. Staff stated that around that time there are shift changes with staff coming in and out, and opening doors. Staff interviews revealed that sometimes the French doors are left opened so that clients can go in and out to the backyard. The incident was captured on surveillance video. It confirmed that C1 walked to the front yard without supervision. Per, C1's Regional Center Individual Program Plan (IPP) client (C1) requires supervision and "lacks safety awareness." C1 "is not able to navigate in the community without staff assistance." C1 is not able to identify or read street signs and does not understand it must stop at a crosswalk.

Allegation: Facility gate is in disrepair. It is alleged that the driveway gate was in disrepair. Based on interviews conducted it was confirmed that the driveway gate was not working properly for approximately four (4) days. Due to windy weather staff placed a rock so that the gate would not swing back and forth. Staff had to manually open the gate. A repair work order was sent on Thursday, April 14, 2022 and on Saturday April 16, 2022 the driveway gate was repaired. Staff were instructed to monitor the clients closely in order to prevent anyone from exiting the facility.

Based on document review and interviews conducted the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22. Civil penalty was assessed for repeat violation 85078(a)(1).


An exit interview was conducted with Hazel Gatan. A copy of the report an appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20220422123536
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 - DE SALES
FACILITY NUMBER: 198601509
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/20/2022
Section Cited
CCR
85078(a)(1)
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85078(a)(1) Responsibility for Providing Care and Supervision. In addition to Section 80078, the following shall apply: The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs.

This requirement was not met as evidenced by:
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Administrator agrees to submit a written plan, proof of staff training, and a copy of training materials by POC due date.



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Based on interviews conducted and records review facility staff failed to provide close supervision as indicated in client (C1's) IPP report. On April 13, 2022 C1 exited the facility without staff supervision. A plumber at the facility notified staff. This poses a potential health and safety risk to persons in care.
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Type B
07/20/2022
Section Cited
CCR
80077.3(a)
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80077.3(a). Care for Clients Who Lack Hazard Awareness or Impulse Control. If a client requires protective supervision because of running/wandering away, supervision may be enhanced by fencing yards, using self-closing latches and gates, and installing operational bells, buzzers, or other auditory devices on exterior doors to alert staff when
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Administrator shall ensure all clients in care are supervised as indicated per their IPP, staff closely supervise all clients at all times, and the auditory alarms and gates are working properly.

Submit a written plan of correction that states how this deficiency was corrected.
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the door is opened. The fencing and devices must not substitute for appropriate staffing. This requirement was not met as evidenced by: On April 13, 2022, C1 exited the facility without staff supervision. C1 has wandering/AWOL behaviors, and per IPP lacks self awareness; which poses 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.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20220422123536
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 - DE SALES
FACILITY NUMBER: 198601509
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/29/2022
Section Cited
CCR
80087(a)
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80087(a) 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 evidenced by:
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Administrator stated the gate was repaired on April 16, 2022. During both complaint visits, the gate was observed to be operable.

**Deficiency was cleared on 4/27/2022.
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Based on interviews conducted the findings indicate that the driveway gate door was not working properly for at least 4 days the week of April 10, 2022- April 16, 2022; which poses 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.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4