<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601510
Report Date: 12/09/2025
Date Signed: 12/09/2025 04:21:17 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
12/01/2025 and conducted by Evaluator Mayra Cota
COMPLAINT CONTROL NUMBER: 28-AS-20251201131004
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:
12/09/2025
UNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Alex Tran, House Registered NurseTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not treat resident with dignity and respect.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Mayra Cota, conducted a 10-day complaint visit to investigate the above-mentioned allegation. LPA, met with Alex Tran, House Registered Nurse, and the reason for the visit was explained. Administrator, Sally Wu, and Yolanda Bosch, Executive Director, were informed about today’s visit telephonically.

The investigation consisted of the following:

During today's visit, LPA obtained copies of staff and client rosters, conducted a tour of the common areas of the home, reviewed Client 1 (C1) facility file including SIRs and obtained copies of C1's Physician Report and Individual Program Plan (IPP). LPA, also conducted interviews with Staff 1 - Staff 5 (S1-S5) and attempted to conduct interviews with Client 1 - Client 5 (C1-C5).

The investigation revealed the following: ****Continues on LIC 9099-C****
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
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-20251201131004
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: 12/09/2025
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
Regarding: Staff did not treat resident with dignity and respect.

It is alleged that a person engaged in mental/emotional abuse toward client after the person informed the client that the person will no longer be working with the client, thus making the client cry.

Interviews with (3) out of (5) staff revealed that the C1 was not observed crying after the one-on-one discussion between person and C1. Staff interviews revealed that after the one-on-one session with the person and the C1, staff were asked by person to check on C1 due to possibly being sad that the person was no longer going to be working with the C1. Staff stated that the C1 did not show signs of having been crying and went about having a normal day. Staff further indicated that the person has always been observed to be cordial and respectful toward the clients, and they never saw the person act emotionally abusive toward anyone. Staff further stated that they are mandated reporters and advocates for clients’ rights and would report any type of abuse to authorities. Interview with S1 indicated that they were not present during the incident and have not received any complaints or reports regarding the person being emotionally abusive to any of the clients in care or not treating them with dignity and respect. Interview with S2 revealed that the person had been asked to wait on informing the C1 that the person was transitioning and will no longer be working with C1; however, S2 stated that the person did not wait and proceeded to talk to C1 during one-on-one discussion at the facility. S2 indicated that prior to the incident, S2 had not received any reports regarding the person being emotionally abusive toward C1 nor any of the other clients in care. LPA attempted to conduct interviews with C1; however, C1 was not responsive to LPA’s questions. LPA also attempted to interview C2-C5 but was unable to due to clients not responding to LPA’s questions. Interviews with staff do not corroborate the allegation that the person was mentally/emotionally abusive to client.

Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Alex Tran, House RN, and a copy of this report was provided.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
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
12/01/2025 and conducted by Evaluator Mayra Cota
COMPLAINT CONTROL NUMBER: 28-AS-20251201131004

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:
12/09/2025
UNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Alex Tran, House Registered NurseTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not report incident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
******This is an amendment of the original report. The purpose of the amendment is to correct an error on the LIC 9099-D (citation). There is no change in the findings. The findings remain the same.***
Licensing Program Analyst (LPA), Mayra Cota, conducted a 10-day complaint visit to investigate the above-mentioned allegation. LPA, met with Alex Tran, House Registered Nurse, and the reason for the visit was explained. Administrator, Sally Wu, and Yolanda Bosch, Executive Director, were informed about today’s visit telephonically.

The investigation consisted of the following:

During today's visit, LPA obtained copies of staff and client rosters, conducted a tour of the common areas of the home, reviewed Client 1 (C1) facility file including SIRs and obtained copies of C1's Physician Report and Individual Program Plan (IPP). LPA, also conducted interviews with Staff 1 - Staff 5 (S1-S5) and attempted to conduct interviews with Client 1 - Client 5 (C1-C5).

The investigation revealed the following:
***Continues on LIC 9099-C****

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
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-20251201131004
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: 12/09/2025
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
Regarding: Staff did not report incident.

It is alleged that staff did not report the incident of alleged abuse to the department.

Interviews with (3) out of (5) staff revealed that the facility does not have a Special Incident Report (SIR) on file at the facility. Interviews with (2) staff indicated that the staff member in charge of sending the SIR to the department has not sent them a copy of the incident which allegedly occurred on 11/5/2025 to keep on file. Interview with (1) staff indicated that an SIR was sent but did not provide confirmation documents during today’s visit. Furthermore, Regional Center did not receive an SIR regarding the incident. Interviews with (2) staff indicated that they are not aware if the facility reported the incident of alleged abuse to the department. Record review conducted by LPA during today’s visit found that there was no SIR dated 11/5/2025 present in C1’s facility file. Interviews with staff and review of records corroborate the allegation that staff did not report the incident of alleged abuse toward client in care.

Based on LPA’s observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations (Title 22), are being cited on the attached LIC 9099 D. An exit interview was conducted with Alex Tran, House Manager, and a copy of this report, LIC 9099-D and Appleal Rights was provided.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20251201131004
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: 12/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2025
Section Cited
CCR
80061(b)(1)(F)
1
2
3
4
5
6
7
80061(b)(1)(F) Reporting Requirements (b) Upon the occurrence...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: (F) Any suspected psychological abuse of any client
1
2
3
4
5
6
7
The Licensee will ensure Special Incident Reports (SIRs) are reported to the appropriate parties in a timely manner. Licensee will provide proof of Reporting Requirements training with staff and submit proof of trainings to LPA by POC due date. Licensee will also send a copy of SIR dated 11/5/2025 by POC due date.
8
9
10
11
12
13
14
This requirement is not met as evidenced by:
SIR regarding alleged emotional abuse dated 11/5/2025, not present in the facility's records/files during time of visit which may pose a potential health and safety risk for clients in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5