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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601603
Report Date: 06/07/2023
Date Signed: 06/07/2023 04:06:00 PM

Substantiated


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
06/01/2023 and conducted by Evaluator Angelica Rea
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230601102511
FACILITY NAME:ELWYN NC - LOS LOTESFACILITY NUMBER:
198601603
ADMINISTRATOR:LAURIE HERNANDEZFACILITY TYPE:
734
ADDRESS:15041 LOS LOTES AVETELEPHONE:
(562) 360-1225
CITY:WHITTIERSTATE: CAZIP CODE:
90605
CAPACITY:5CENSUS: 5DATE:
06/07/2023
UNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Laurie HernandezTIME COMPLETED:
04:25 PM
ALLEGATION(S):
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Facility did not have sufficient staffing to meet the needs of clients.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angelica Rea conducted a visit in response to the above allegation. On today's visit, LPA met with Administrator, Laurie Hernandez, who allowed entry into the facility and assisted with today's visit.

Regarding the allegation that : Facility did not have sufficient staffing to meet the needs of clients, the investigation consisted of interview(s) with Administrator, Staff #1, review of Department of Developmental Services (DDS) corrective action report, and facility staffing schedules for period of September 2022, and October 2022.

The investigation revealed that on 10/6/22, DDS conducted a semi-annual review for Elwyn-NC Los Lotes. As part of the DDS review, staff schedules were reviewed and it was observed that the facility did not have sufficient staffing during the weeks of 9/12/22 -9/18/22, 9/19/22 - 9/25/22, 9/26/22, and 10/3/22 - 10/9/22.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023
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 3
Control Number 28-AS-20230601102511
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 - LOS LOTES
FACILITY NUMBER: 198601603
VISIT DATE: 06/07/2023
NARRATIVE
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Administrator stated that the facility has completed the corrective action plan that was issued. LPA observed a copy of final corrective action plan dated 5/30/23. Administrator stated that they have hired additional staff as required.

Based on LPA's interviews and records reviewed, the preponderance of evidence standard has been met, therefore the allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.

Exit interview was conducted, and copy of report and appeal rights were provided to Ms. Hernandez.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20230601102511
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 - LOS LOTES
FACILITY NUMBER: 198601603
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/07/2023
Section Cited
CCR
80065(a)
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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 was not met as evidenced by :
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Facility has hired additional staff to comply with the requirements. Administrator stated that they hired a full time Registered Nurse which puts the facility in compliance with the required RN hours.

Deficiency will be cleared on today's visit.
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LPA observed that based on the facility's program design, the facility had insufficient staff to meet the needs of the clients in care, on the following dates : 9/12/22 -9/18/22, 9/19/22 - 9/25/22, 9/26/22 -10/2/22 and 10/3/22 - 10/9/22. This 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: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3