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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601510
Report Date: 07/24/2025
Date Signed: 07/24/2025 03:32:50 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
02/04/2025 and conducted by Evaluator Christian Gutierrez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250204110211
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:
07/24/2025
UNANNOUNCEDTIME BEGAN:
12:56 PM
MET WITH:Alex Tran RNTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Resident sustained a fracture due to staff neglect
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Registered Nurse (RN) Alex Tran and explained the purpose of the visit.

The investigation consisted of the following: During the initial visit conducted on 02/05/2025, LPA conducted an unannounced Health and safety inspection LPA toured the facility and obtained copies of the following documents: staff roster, and client roster. During tour LPA observed a sufficient supply of feeding food for G-tube and observed the residents to identify any signs of neglect, abuse, or other immediate health and safety threats. LPA did not observe any immediate health and/or safety concerns. LPA checked two (2) random clients medication no discrepancies found. From 02/19/25 – 04/30/25 investigator J. Canto with the Investigations Branch (IB) investigated the reported allegation. During today’s visit LPA Gutierrez delivered findings.

See LIC 9099C
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
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-20250204110211
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ELWYN NC - DOREEN
FACILITY NUMBER: 198601510
VISIT DATE: 07/24/2025
NARRATIVE
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. The investigation revealed the following:

Allegation: Resident sustained a fracture due to staff neglect

It is alleged that C1 sustained a fracture due to staff neglect. This allegation was investigated by Investigations Branch (IB) investigator J. Canto which revealed the following:

During interviews with facility staff members and C1’s mother it was revealed that C1 was not at his/her baseline and appeared to be in distress and pain on or about 08/13/2024. Facility reported to C1’s primary care physician who ordered x-rays and prescribed pain medication. It was revealed C1 sustained a tibial fracture. The facility staff theorized the injury may have occurred during repositioning or the use of Hoyer lift. Primary care physician was also interviewed, theorized the incident occurred during repositioning or transfer. Based upon interviews and record review fracture occurred but there was no evidence that C1 sustained fracture due to staff neglect.

Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was given to RN.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
02/04/2025 and conducted by Evaluator Christian Gutierrez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250204110211

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:
07/24/2025
UNANNOUNCEDTIME BEGAN:
12:56 PM
MET WITH:Alex Tran RNTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff did not ensure resident received medical attention in a timely manner
Staff did not follow reporting requirements
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Registered Nurse (RN) Alex Tran and explained the purpose of the visit.

The investigation consisted of the following: During the initial visit conducted on 02/05/2025, LPA conducted an unannounced Health and safety inspection LPA toured the facility and obtained copies of the following documents: staff roster, and client roster. During tour LPA observed a sufficient supply of feeding food for G-tube and observed the residents to identify any signs of neglect, abuse, or other immediate health and safety threats. LPA did not observe any immediate health and/or safety concerns. LPA checked two (2) random clients’ medication no discrepancies found. From 02/19/25 – 04/30/25 investigator J. Canto with the Investigations Branch (IB) investigated one (1) reported allegation. During today’s visit LPA Gutierrez interviewed three (3) staff, obtained special incident report (SIR), and delivered findings.

See LIC 9099C
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20250204110211
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ELWYN NC - DOREEN
FACILITY NUMBER: 198601510
VISIT DATE: 07/24/2025
NARRATIVE
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Allegation: Staff did not ensure resident received medical attention in a timely manner

It is alleged that C1 sustained an injury while in care and staff acted inadequate for C1’s change of condition which left C1 in pain and discomfort. This allegation was investigated by Investigations Branch (IB) investigator J. Canto which revealed the following:

During interviews with facility staff members, C1’s mother, and primary care physician (PCP) it was revealed that C1 appeared to be in distress and pain on or about 08/13/2024. Facility reported to C1’s primary care physician who ordered x-rays and prescribed pain medication. Initial Xray revealed no fracture however C1 remained in pain showing signs of discomfort by crying and grimacing for two more days. Facility stated they requested additional x-rays a claim PCP denies. On 08/17/2024 C1’s mother noted swelling and at that time facility contacted PCP who advised taking C1 to hospital. Once taken to hospital it was revealed that C1 sustained a tibial fracture. The facility failed to identify continues signs of discomfort and failed to seek timely medical attention for C1. The allegation of medical attention in a timely manner is substantiated.

Facility staff did not follow reporting requirements. It is alleged staff failed to report special incident regarding C1. C1 began to experience pain and discomfort and was taken to primary care physician on 08/13/2024 for x-rays to foot. C1 remained in discomfort for the next two days it wasn’t until 08/17/2024 when C1 was taken to emergency room that a special incident report (SIR) was submitted to Community Care Licensing and East La Regional Center, based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code.

An exit interview was conducted. A copy of the report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20250204110211
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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: 07/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/25/2025
Section Cited
CCR
80075(a)
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80075 Health Related Services
(a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services.
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A corrective action plan was created and all staff have been retrained of the importance of timely medical care.
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Based on record review facility did not seek timely medical care for C1 that resulted in tibial fracture.This poses an immediate health and safety risk to clients in care.
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Type B
07/31/2025
Section Cited
CCR
80061(b)(1)(E)
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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. 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:(E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
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Licensee will retrain staff on SIR reporting according to Title 22.
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This deficiency is evidenced by the following:
Facility did not submit any SIR's for C1 change of condition until four days after initial occurrence. Which poses a potential risk to clients in care.
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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: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5