198601509-1-28-2022-28-AS-LHIS-CCQTZK-20220321151027

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601509
Report Date: 01/28/2022
Date Signed: 01/28/2022 04:20:48 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
01/24/2022 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220124133141

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:	01/28/2022
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Jennifer Silva, House Manager		TIME COMPLETED:	04:25 PM

ALLEGATION(S):

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Staff are not wearing masks.

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 House Manager Jennifer Silva. Administrator Hazel Gatan was explained the purpose of the visit telephonically.

The investigation consisted of the following: A tour of the physical plant was conducted. Staff (S1- S5) were interviewed. Administrator and Staff (S2) were interviewed telephonically. No clients were interviewed because 3 of the 4 clients present are non-verbal. Copies of COVID-19 Mitigation Plan, LIC 500 Personnel Report and LIC 9020 Register of Facility Clients/Residents, and staff (S2 & S3) staff training logs were reviewed and obtained.

See LIC 9099C for report continuation.

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220124133141

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: 01/28/2022

NARRATIVE

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Allegation: "Staff are not wearing masks." It is alleged that two staff (S1 & S2) do not wear masks at all while working in the home. According to the report, when the doorbell rings staff that are not wearing masks immediately put the mask on before answering the door. It was reported that previous Administration staff were made aware that some staff do not follow COVID-19 infection control protocols i.e mask mandate and social distancing, but there has been no disciplinary action or re-training. A total of five (5) staff were interviewed all denied this allegation. Staff (S1 and S2) denied allegation and stated that the only time they do not wear surgical and/or N-95 masks is when they are eating or drinking during their break time. Staff are allowed to eat indoors at separate times. Three (3) of the 4 clients in the home are non-verbal and were not interviewed. Client (C4) is able to speak but was not in the home. LPA reviewed and obtained staff (S1 & S2) training logs, which indicated both staff have received training on COVID-19 infection control topics. However, based on staff interviews the majority of COVID-19 training topics have been presented in written format. Staff are provided training information sheets, and then asked to sign a log stating they read the training forms. The findings indicate that during the course of the COVID-19 pandemic Administration staff have conducted very little in-person training, and protocols have been presented in writing.

A copy of the COVID-19 Mitigation Plan was obtained. It states "Staff has been trained on how to correctly don and doff PPE per CDC guidelines and Elwyn Nursing policies. Annual and as needed competency on all staff will be conducted to ensure competency in the appropriate use of PPE." There is insufficient evidence to prove this allegation.

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.

An exit interview was held with House Manager Jennifer Silva. A copy of this report was issued.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022

LIC9099 (FAS) - (06/04)

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