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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601603
Report Date: 12/19/2025
Date Signed: 12/19/2025 04:33:16 PM

Substantiated


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
12/16/2025 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20251216082805
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:
12/19/2025
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Edward Velarde- LVNTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff did not give resident medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 12/19/2025 regarding the above allegation. During today’s visit LPA Ramirez was greeted by Licensed Vocational Nurse (LVN)- Edward Velarde and explained the purpose of the visit.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff Roster (LIC 500), Staff#1 - 3 interviews (S1 – S3), Attempted staff interview of staff#6 (S6), Attempted client interview of client#1-5 (C1-C5), Eastern Los Angeles Regional Center Vendor Special Incident Report (dated 10/29/2025), Medication Administration Record (MAR) for client#3 (C3) dated October 2025, Eastern Los Angeles Regional Center Corrective Action Plan (CAP), Staff re-training materials and sign in sheet (dated 11/18/25), Personnel record update for staff#6 (S6), and physical plant tour.

SEE 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025
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 3
Control Number 28-AS-20251216082805
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 - LOS LOTES
FACILITY NUMBER: 198601603
VISIT DATE: 12/19/2025
NARRATIVE
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The investigation revealed the following: regarding the allegation “Staff did not give resident medication.” It is alleged staff did not administer C3 their medication on 10/25/25 and 10/26/25. During record review, LPA Ramirez observed Eastern Los Angeles Regional Center Vendor Special Incident Report (dated 10/29/2025), which indicated that on 10/27/25, staff reported to S2 that C3 was not administered their scheduled prescription of Diltiazem 30mg tablet at 12am on 10/15/25 & 10/26/25. This report revealed that S6 logged that they administered C3 their medication however, two (2) tablets of Diltiazem 30mg were observed still in C3’s bubble pack for days 10/25/25 & 10/26/26 for the 12am dosage. Review of C3’s MAR for October 2025 revealed that S6 logged C3’s vitals as follows: 10/25/25- HR- 88 & SBP- 140 and on 10/26/25- HR- 58*entry appears to be altered* & SBP- 119. Review of C3’s physician orders revealed that C3 has a standing order for Diltiazem 30mg tablet to be administered at 8am, 4pm and 12am and only to be administered if C3’s SBP (Systolic Blood Pressure) is<100 or if HR (Heart Rate) <60*. Staff interviews revealed that based on C3’s physician orders and vitals taken on 10/25/25 & 10/26/25 by S6, C3 should have been administered Diltiazem 30mg tablet at 12am on 10/25/25 & 10/26/25. Interview with S2 and S1 revealed they observed C3’s medication of Diltiazem 30mg tablet still in bubble pack day for 10/25/25 & 10/26/25. LPA Ramirez attempted to interview S6 via telephone but was unsuccessful. LPA Ramirez attempted to interview C1, C2, C4 and C5 however, due to cognitive impairments, LPA Ramirez was unable to gather meaningful responses. C3 was not at the facility and unable to be interviewed. Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated.

One (1) type A deficiency has been cited during this complaint investigation. Exit interview was conducted. A copy of this report, 9099-D and appeals rights was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20251216082805
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 - LOS LOTES
FACILITY NUMBER: 198601603
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
12/19/2025
Section Cited
CCR
80065(a)
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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 was not met as evidenced by: S6 did not administer C3 their
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Staff re-training on medication administration was conducted on 11/18/25. No further is required to clear deficiency. LPA Ramirez obtained a copy of staff sign in sheet and re-training material during visit.
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prescribed medication and inaccurately logged that C3 was administered medication. This poses an immediate risk to the health, safety, or personal rights of persons 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.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025
LIC9099 (FAS) - (06/04)
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