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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601510
Report Date: 07/28/2023
Date Signed: 07/28/2023 03:18:19 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
06/22/2023 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230622154329
FACILITY NAME:ELWYN NC - DOREENFACILITY NUMBER:
198601510
ADMINISTRATOR:HAZEL ANGELI GATANFACILITY TYPE:
734
ADDRESS:5116 DOREEN AVETELEPHONE:
(626) 941-6562
CITY:TEMPLE CITYSTATE: CAZIP CODE:
91780
CAPACITY:5CENSUS: 5DATE:
07/28/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Staff #1TIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility staff failed to conduct wellness checks on clients as required.
Facility staff failed to take preventative measures to ensure the health and saftey of clients in care.
Facility staff are not following client's IPP's.
Facility staff failed to report special incidents.
Facility staff failed to document medication administered on the MAR.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted a subsequent complaint investigation visit to deliver findings on 07/28/23 regarding the above allegation(s). LPA Ramirez was met by Staff #1(S1) and explained the purpose of the visit.

The investigation consisted of the following: Initial complaint investigation was conducted on 6/28/23 by LPA Ramirez and needs further was required. LPA Ramirez requested and obtained copies of Staff Roster (LIC 500), Client Roster (LIC 9020), Staff #1 -2 interviews (S1- S2), Client #1 (C1): Face Sheet, Medication Administration Record (MAR) for April & May of 2023, Client #2 (C2): Physician Record Visit dated 5/19/23, Physician’s Report dated 1/15/23, Physician’s Orders dated 5/2/23, Eastern Los Angeles Regional Center Quartey Report dated 1/23/23, Eastern Los Angeles Regional Center Corrective Action Plan dated 6/12/23 and physical plant tour.

SEE 9099-C for continuation.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023
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 5
Control Number 28-AS-20230622154329
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ELWYN NC - DOREEN
FACILITY NUMBER: 198601510
VISIT DATE: 07/28/2023
NARRATIVE
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The investigation revealed the following-Regarding Allegation(s): Facility staff failed to conduct wellness checks on clients as required. It is alleged staff failed to conduct wellness checks on clients. Per Eastern Los Angeles Regional Center Corrective Action Plan (CAP) dated 6/12/23, on May 3, 2023, an unannounced visit was conducted by DDS Clinical Branch Management team from the Office of Statewide Clinical Services, Witness #1 (W1) and Witness #2 (W2), documented concerns and substantial inadequacies based on their visit to the facility. Per CAP, W1 reviewed and identified 11 occasions between 1/4/23 through 5/1/23, in which staff failed to document wellness checks per clients’ medical needs. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Facility staff failed to take preventative measures to ensure the health and safety of clients in care. It is alleged staff did not take preventive measures that align with C1's IPP. C1 has an identified Treatment Order goal that indicated C1 is to “ use left arm wheelchair padding 2 hours on and 2 hours off during daytime and to help maintain proper posture.” CAP report revealed during the month of May 2023, there is no data collection documented and all squares on this Treatment Order sheet were left blank. New skin irritations on elbow were documented by W1 on CAP report. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Facility staff are not following client's IPP's. C1 has an identified goal to have ointment placed as to ensure proper skin integrity. For skin integrity purposes and preventative measures, staff are to document the amount of times staff is applying ointment at every shift. Staff did document amount of times ointment was applied however, in the month of May 2023, the ointment applications increased to 241, a total of 31 more applications from the month prior. Staff did not follow up as to why additional preventative skin maintenance ointment applications were needed. According to CAP report “This lack of advocacy for preventive measures does not align to the IPP goal of “Will have healthy, intact skin as evidenced by absence of redness, irritation and flakiness.” W1 also noted C1 had documented skin assessments done and several observations pertaining to new skin irritations were noted. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

SEE 9099-C for continuation.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20230622154329
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ELWYN NC - DOREEN
FACILITY NUMBER: 198601510
VISIT DATE: 07/28/2023
NARRATIVE
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Facility staff failed to report special incidents. It is alleged staff failed to report special incident regarding C1. Per CAP report, on 5/6/23, new skin condition was documented as a “blister” for C1. There was no Special Incident Report (SIR) for this and other skin changes, per W1. C2 has had their Gastronomy Tube (g-tube) dislodged in the a.m. during the month of May 2023 without the proper documentation and SIR reporting. Per Administrator Gatan, discussion with Eastern Los Angeles Regional Center on 7/19/23, moving forward, facility will document g-tube dislodgement by completing SIR. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Facility staff failed to document medication administered on the MAR. It is alleged facility staff did not document in MAR, medication given to clients. Per CAP report dated 6/12/23, facility staff did not document medication given to C2 on MAR on 5/13/23. C2's g- tube ballon volume was not being documented by being initialed when checked in MAR. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Deficiencies are being cited. Exit interview was conducted. A copy of this report, 9099-D, and appeals rights was provided.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20230622154329
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ELWYN NC - DOREEN
FACILITY NUMBER: 198601510
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/28/2023
Section Cited
CCR
80061(b)(1)(D)(E)
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Title 22, Division 6
Chapter 1
Article 06. Continuing Requirements
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 during its normal business hours.
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Licensee will retrain staff on SIR reporting according to Title 22. As of 7/28/23, the licensee conducted in service training with staff on 7/05/23, 7/10/23, 7/11/23, and 7/19/23. No further action is warranted at this time.
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 In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.
(1) Events reported shall include the following:



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1. For community care facilities that serve children, a pregnancy or termination of a pregnancy does not, in and of itself, constitute an unusual incident unless it meets the criteria specified for mandated reporting in Penal Code section 11166 (a). This requirement is not met as evidence by:
Facility staff failed to report SIR regarding C1 and C2 per Title 22.
Type B
CCR
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(D) Any injury to any client which requires medical treatment.
(E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
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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: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20230622154329
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ELWYN NC - DOREEN
FACILITY NUMBER: 198601510
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/28/2023
Section Cited
CCR
80078(a)
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Title 22, Division 6
Chapter 1
Article 06. Continuing Requirements
80078
Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision as necessary to meet the client's needs.
This requirement is not met as evidence by:

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Licensee will retrain staff on care and supervision according to clients needs per Title 22. As of 7/28/23, Licensee conducted in service training on various days in July regarding care and supervision. No further action is required at this time.
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Facility staff failed to conduct wellness check, take preventative measures, and facility staff are not following client's IPP.
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Type A
07/28/2023
Section Cited
CCR
80065(a)
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Title 22, Division 6
Chapter 1
Article 06. Continuing Requirements
80065
Personnel Requirements
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Facility staff failed to document C2's ballon volume in MAR and medication being administered on MAR for 5/13/23.
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(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.
This requirement is not met as evidence by:
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Licensee will re-train staff on the importance of documenting medications or treatment on MAR in accordance to the clients' IPP and/or Health Care Plan. As of 7/28/23, Licensee has conducted in service training regarding MAR and medication on various days in July of 2023.
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: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5