198601509-10-26-2021-28-AS-WSHO-C9PUMW-20211214144301

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601509
Report Date: 10/26/2021
Date Signed: 10/26/2021 03:46:21 PM

Unsubstantiated

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
08/03/2021 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210803085303

FACILITY NAME:	ELWYN NC - DE SALES		FACILITY NUMBER:	198601509
ADMINISTRATOR:	EDWARD VELARDE		FACILITY TYPE:	735
ADDRESS:	610 N DE SALES ST		TELEPHONE:	(626) 872-6983
CITY:	SAN GABRIEL	STATE: CA	ZIP CODE:	91775
CAPACITY:	4	CENSUS: 4	DATE:	10/26/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Bryan Gray Direct Support Professional		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Lack of supervision resulted in resident AWOL.
Staff imitates resident resulting resident to be upset.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst's Glenn Trueman made an unannounced visit to the facility and was greeted by Bryan Gray Direct Support Professional and explained the reason for the visit.
The purpose of the visit is to deliver the findings from the original complaint dated 08/03/2021.
Initial visit was conducted on 08/04/21 and due to the situation surrounding the Coronavirus LPA interviewed the Administrator telephonically at 2:45 P.M.
On 09/09/21 a subsequent visit was conducted and from 9:45 AM to 10:00 AM Administrator was interviewed.
From 10:00AM to 10:15 AM Client 1 was interviewed.
From 10:15 AM to 10:30 AM attempts were made to interview Client's 2 -4 who were non-verbal and limited in their responses. From 10:30 to 11:30 Staff 1-3 were interviewed.
In regards to the allegation Lack of supervision resulted in resident AWOL, based on interviews conducted with staff, clients, Regional Center Representative and information gathered from facility client notes and Individual Program Plan (IPP) it was revealed under Psychiatric Behavioral on IPP dated 09/24/2020 that

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/26/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021

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 2

Control Number 28-AS-20210803085303

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: 10/26/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Client 1 displays the following behaviors at home: physical aggression, emotional outbursts, non-compliance, fabrication, self injurious, AWOL and inappropriate social behavior.
Client notes revealed on 08/01/21 that Client 1 at 4:15 P.M. attacked staff and attempted to bite staff. Attempts of biting, kicking and screaming continued.
Client 1 ran out of bedroom and opened the gate and ran out with staff behind who were able to redirect back to the room. 7:30 PM Client 1 was back in the room and calm.
Interviews with staff revealed that Client 1 has had medication challenges and would try to AWOL and they would redirect and reinforce. Said that behaviors have been intense and there has been concern with self injury.
Said that staff were right behind Client 1 when she broke through the gate.
Interview with Regional Center Representative who stated that when Client 1 had AWOL'd facility staff were right behind. Client 1 had been outside for not too long and staff were trying to soothe and acted proactively to redirect back to the facility.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation occurred, therefore the allegation is Unsubstantiated.

In regards to the allegation Staff imitates resident resulting resident to be upset, based on interviews conducted and information gathered Client 1 stated that everything is okay with staff and likes the Administrator as a favorite staff.
Staff interviewed stated that they have not heard anything unprofessional and would report it if they did.
There has not been any scenarios where she was talked to bad.
Voices have been stern and not in a mean way for Client 1's safety during behaviors.
Staff have not seen signs of anyone imitating Client 1 and stated that she will cry for the Administrator and misses him.
Said she will not want to call her mom and will say call Administrator.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation occurred, therefore the allegation is Unsubstantiated.

Exit interview conducted.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/26/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2