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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601509
Report Date: 08/02/2024
Date Signed: 08/02/2024 12:18:15 PM

Document Has Been Signed on 08/02/2024 12:18 PM - 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 CA - DE SALESFACILITY NUMBER:
198601509
ADMINISTRATOR/
DIRECTOR:
MARTIN SYFACILITY TYPE:
735
ADDRESS:610 N DE SALES STTELEPHONE:
(626) 872-6983
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY: 4CENSUS: 3DATE:
08/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:35 AM
MET WITH:Eric Espartero, Interim AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Galarza conducted a Case Management- Incident visit to follow up on an SOC 341 Report of Suspected Dependent Elder Abuse incident report dated 7/26/2024. LPA met with Interim Administrator Eric Espartero. The purpose of today's visit is to check on the health & safety of residents in care.

According to SOC 341, the facility reported suspected physical abuse of a resident. It states that resident (R1) was bitten and scratched by staff (S1) on 7/24/24.

Staff were interviewed and stated that on 7/24/24, R1 returned from day program and became physically aggressive towards DSP/Staff when questioned about the food item she got from the refrigerator. The resident has liquid intake restrictions due to a medical condition. Staff stated that R1 bit their own hand and scratched the wrist area after behavior incident. Facility staff called the Regional Center crisis hot line and a representative conducted a same day visit. No health and safety concerns were observed.

LPA reviewed the residents file and noted that R1 has self-injurious behaviors that include biting, scratching, and physical aggression. Staff completed a body check assessment and other licensee required forms as required.

Resident (R1) was not present during today's visit. Staff (S1 & S2) were interviewed, of which both denied that the resident was bitten and scratched by staff.

No health and safety concerns were observed during the visit.

Exit interview conducted and a copy of the report was given to Mr. Espartero.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2024
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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