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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601509
Report Date: 09/08/2021
Date Signed: 09/08/2021 03:31:01 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
09/01/2021 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210901142858
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:
09/08/2021
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Edward Velarde, AdministratorTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Client was allowed to leave the facility without staff supervision.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted an initial complaint visit to investigate the above allegations. The purpose of the visit was discussed with DSP staff Jennifer Avila. Administrator Edward Velarde arrived shortly after.

The investigation consisted of the following: A tour of the interior and exterior physical plant was conducted. Staff (S1- S4) and client (C2) were interviewed. Client (C1) and clients (C3-C4) are non-verbal and were not interviewed. One (1) neighborhood witness was also interviewed. Client (C1's) file documents were obtained [Identification and Emergency Information, Physician Report, Preplacement Appraisal, Individual Program Plan (IPP), ISP, Behavior Progress Report, Appraisal Needs and Service Plan, resident roster, and LIC 500 Personnel Report. An incident report had been previously submitted to CCL.

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: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
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-20210901142858
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: 09/08/2021
NARRATIVE
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Allegation: Client was allowed to leave the facility without staff supervision. Based on interviews conducted and document review the findings indicate that on September 1, 2021 client (C1) exited facility property unsupervised. At approximately 1:00 PM the client was seen by three neighbor witnesses walking in the middle of street two houses down from the facility. Client (C1) approached the neighbor's car as it pulled into the driveway. Witnesses stated C1 appeared disoriented and was not able to communicate. NOTE: Client (C1) is non-verbal with diagnosis of profound intellectual disability. Client (C2) was interviewed and confirmed that C1 left the facility.

Per client (C1's) Regional Center Individual Program Plan (IPP) the client is not allowed to be left unsupervised and has "very little knowledge of street and community safety." A total of two staff (S1 & S2) were on duty during the incident. They were assisting another client in the bathroom. The third staff was taking a car lunch break outside. Client (C1) exited through the dining room door and left the facility property through the side gate door that was left unlocked by another new staff that had left earlier. According to community witness a staff was observed parked outside while C1 was with the neighbors. Two neighbors walked over client (C1) to the facility after being found in the street. The client did not sustain any injuries. The exit doors have auditory alarms that at times cannot be heard depending on the location of where staff are at inside the home. Staff stated that client (C1) was unaccounted for a total of 4 minutes. LPA reviewed video surveillance footage and confirmed the total amount of time the client was unsupervised outdoors.

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

An exit interview was conducted with Administrator Edward Velarde 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: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20210901142858
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: 09/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/22/2021
Section Cited
HSC
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 by evidence of:
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Administrator agreed to provide a written plan stating what was done in regards to this incident. In addition, all staff shall receive re-training on resident supervision, and review each client's IPP to determine the needs of the clients and staff responsibilities. Provide proof of a written statement, and staff in-service training logs.

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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 Sep. 1, 2021 C1 exited the facility and was observed walking in the middle of street. On duty staff were not aware. C1 was returned to the home by neighbor witnesses.
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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: 09/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3