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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601509
Report Date: 04/14/2022
Date Signed: 04/15/2022 09:21:19 AM

Document Has Been Signed on 04/15/2022 09:21 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
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:
04/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:25 PM
MET WITH:Sabyne Francis, LVNTIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted a case management visit to issue a deficiency observed during a complaint investigation. LPA explained the purpose of this visit to LVN, Sabyne Francis.

Based on interviews conducted with Staff for complaint #28-AS-20220328110826, four (4) out of six (6) staff observed Client #1 with a bruise on the left leg towards the beginning of week 3/21/22 - 3/25/22. They stated it was reported, however, there was no documentation of the bruise on record. Client #1's large bruise was not reported until 3/25/22. Community Care Licensing received the Usual Incident Report for this incident, which only documented the bruise on 3/25/22 after the Administrator learned about it and the police were involved. There were no incident report submitted when staff first observed Client #1's bruise.

A deficiency is cited on the LIC809D in accordance to Title 22 regulations.

An exit interviewed was conducted and a copy of this report was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 04/15/2022 09:21 AM - It Cannot Be Edited


Created By: Cynthia D Chan On 04/14/2022 at 04:45 PM
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 - DE SALES
FACILITY NUMBER: 198601509

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/21/2022
Section Cited
CCR
80061(b)(E)

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80061 Reporting Requirements (b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day...E) Any unusual incident ...threatens the physical or emotional health or safety of any client.
This requirement is not met as evidenced by:
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The Administrator shall conduct an in-service training on observation, documentation, and reporting requirements for clients. The training log shall be submitted to LPA by POC due date 4/21/22.
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Based on interviews and record review, Client #1's bruise initially observed by staff was not documented or reported to CCL which poses a potential health and safety risk to clients 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.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022


LIC809 (FAS) - (06/04)
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