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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601809
Report Date: 08/16/2021
Date Signed: 08/16/2021 02:56:50 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/25/2020 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20200925152822
FACILITY NAME:ELWYN NC - BABCOCKFACILITY NUMBER:
198601809
ADMINISTRATOR:FAITH NDEGWAFACILITY TYPE:
734
ADDRESS:5149 BABCOCK AVETELEPHONE:
(408) 558-1500
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY:5CENSUS: 3DATE:
08/16/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Eivet Azizian LVNTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility staff are not following Regional Center ratios
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent visit for the above allegation. LPA met with and explained the reason for the visit. LPA met with LVN Eivet Azizian and explained the reason for the visit. LPA spoke to Administrator Samantha Toder via telephone who stated Eivet can sign in her place.

During the investigation, LPA conducted a physical plant tour virtually on 10/02/2020 as well as interviewed Administrator. On 6/29/2021, LPA conducted interviews with facility staff, and other relevant parties. LPA also gathered and reviewed facility documentation pertinent to the allegation.

It was alleged that Facility staff are not following Regional Center ratios. LPAs interview with facility staff revealed there were multiple shifts where they were not able to comply with Regional center ratios for Resident 1 (R1), specifically when R1 was first admitted into the facility.
(Continued on 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2021
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 29-AS-20200925152822
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ELWYN NC - BABCOCK
FACILITY NUMBER: 198601809
VISIT DATE: 08/16/2021
NARRATIVE
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(Continued from 9099)

LPA record review of staffing schedule for R1 further revealed there were multiple shifts in September of 2020, where the Regional Center ratio requirements were not met by facility staff. Based on information gathered during this and previous visits, the department has sufficient evidence to determine the facility staff are not following Regional Center Ratios. Therefore, the above allegation is SUBSTANTIATED at this time.

The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 29-AS-20200925152822
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELWYN NC - BABCOCK
FACILITY NUMBER: 198601809
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/16/2021
Section Cited
CCR
82065.5(a)(1)
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82065.5 Staff-Client Ratio -(a)(1) For Regional Center clients, staffing shall be maintained as specified by the Regional Center.

This requirement was not met as evidence by:

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POC was cleared during the visit Administrator provided schedule that indicates facility is following the approved Regional Center ratio for R1. Scheduling appeared to be sufficient at this time.
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Based on LPAs record review and interviews, the facility failed to follow the approved Regional Center ratio for R1. This poses an immediate health and safety risk for residents 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: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3