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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601809
Report Date: 10/18/2021
Date Signed: 10/18/2021 10:06:21 AM

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
10/14/2021 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20211014150233
FACILITY NAME:ELWYN NC - BABCOCKFACILITY NUMBER:
198601809
ADMINISTRATOR:SAMANTHA TODERFACILITY TYPE:
734
ADDRESS:5149 BABCOCK AVETELEPHONE:
(818) 287-5416
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY:5CENSUS: 5DATE:
10/18/2021
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Sam Toder and Eivet AzizianTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Failure to follow the Plan of Operation regarding staffing hours
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced visit for the above allegation. The LPA spoke with Administrator Samantha Toder over the phone and explained the reason for the visit. Today, the LPA interviewed staff at 9:03 a.m., 9:05 a.m and 9:45 a.m., and reviewed records at 9:29 a.m.

Regarding the allegation, it was alleged that this facility experienced a deficiency of staffing hours from 8/30/2021 – 09/05/2021 and from 09/06/2021 – 09/12/2021, as there needs to be a registered nurse on duty a minimum of eight hours per week per client. During those week(s), there were 5 clients in the home, which required a total of 40 hours. Interviews and documentation review confirmed that the required hours were deficient approximately 20 hours from 8/30/2021 – 09/05/2021 and approximately 14 hours from 09/06/2021 – 09/12/2021. The Administrator confirmed there was a staffing shortage and have since implemented a plan to ensure sufficient hours. Based on the information obtained, this allegation is deemed Substantiated at this time. Per the California Code of Regulations (CCR), Title 22, the following deficiencies were observed and cited: (Refer to LIC 9099-D). Exit interview conducted. A copy of the report was provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021
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 2
Control Number 29-AS-20211014150233
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: 10/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/19/2021
Section Cited
CCR
80022(f)
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80022(f) Plan of Operation. The facility shall operate in accordance with the terms specified in the Plan of Operation and may be cited for not doing so.
This requirement was not met as evidenced by:

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The Administrator has agreed to the following:
1. The facility hired a full time Registered Nurse on 10/11/2021, who is on site a minimum of 40 hours per week.
2. During today's visit, the Administrator submitted a Plan of Action, detailing the efforts in meeting staffing requirements
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Based on interview and record review, the licensee did not comply with the section cited above, as the facility did not meet the required eight hours of registered nursing hours per client per week for two consecutive weeks, which poses an immediate health and safety risk to clients in care.
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Plan of Correction met at this time.
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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: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2