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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601809
Report Date: 08/15/2024
Date Signed: 08/15/2024 04:22:17 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
08/30/2023 and conducted by Evaluator Teresa Camara
COMPLAINT CONTROL NUMBER: 29-AS-20230830100407
FACILITY NAME:ELWYN NC - BABCOCKFACILITY NUMBER:
198601809
ADMINISTRATOR:HAZEL LAZAGA GATANFACILITY TYPE:
734
ADDRESS:5149 BABCOCK AVETELEPHONE:
(818) 287-5416
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY:5CENSUS: 4DATE:
08/15/2024
UNANNOUNCEDTIME BEGAN:
10:43 AM
MET WITH:Laurie HernandezTIME COMPLETED:
04:50 PM
ALLEGATION(S):
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Staff are not properly trained.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Teresa Camara and Erica Mosley conducted an initial complaint visit. LPAs were joined by North Los Angeles Regional Center (NLARC) Quality Assurance Specialist (QAS) Lisseth Carrillo. LPAs initially met with the staff LVN. Program Administrator Laurie Hernandez arrived at the facility 12:30 p.m. LPAs explained the reason for the visit.

During today’s visit LPAs conducted a physical plant tour at 11:00 a.m. LPAs conducted interviews with staff starting at 10:55 a.m. LPAs reviewed medications and documents starting at 11:08 a.m. During a previous visit on 8/30/2023, LPA Camara met with the house manager and requested the manager email records to LPA once they were located.

Continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
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 29-AS-20230830100407
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ELWYN NC - BABCOCK
FACILITY NUMBER: 198601809
VISIT DATE: 08/15/2024
NARRATIVE
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(continued from LIC9099)

During the visit on 8/30/2023, LPA requested staff training and medical documents for Client 1 (C1) from the house manager. At the time of the visit there was on site training being conducted and the house manager was not able to locate the documents LPA was requesting. LPA never received the requested documents from the house manager.

During the visit today, 8/15/2024, LPAs requested the training documents from the staff LVN. The LVN recalled receiving some training for C1's new medical condition. The LVN also recalled there were respiratory therapists assigned to the facility daily. However, other staff did not recall receiving training regarding the new special medical needs of C1. In addition, the LVN was not able to locate documentation showing the training had occurred.

Due to lack of documentation to support staff received training for C1's new medical condition, the allegation Staff are not properly trained is deemed Substantiated at this time.


Per the California Code of Regulations (CCR), Title 22, the following deficiency was observed and cited: (Refer to LIC 9099-D). Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20230830100407
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: ELWYN NC - BABCOCK
FACILITY NUMBER: 198601809
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/23/2024
Section Cited
CCR
80065(f)
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80065 Personnel Requirements(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.
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Licensee will provide a written statement of understanding regarding the future need for training and maintaining training records for all staff and provide the statement to CCL on or before 8/23/2024.
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This requirement in not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above as some staff did not receive training and there was no evidence of the training for C1's condition, which posed a potential health risk to 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: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
08/30/2023 and conducted by Evaluator Teresa Camara
COMPLAINT CONTROL NUMBER: 29-AS-20230830100407

FACILITY NAME:ELWYN NC - BABCOCKFACILITY NUMBER:
198601809
ADMINISTRATOR:HAZEL LAZAGA GATANFACILITY TYPE:
734
ADDRESS:5149 BABCOCK AVETELEPHONE:
(818) 287-5416
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY:5CENSUS: 4DATE:
08/15/2024
UNANNOUNCEDTIME BEGAN:
10:43 AM
MET WITH:Laurie HernandezTIME COMPLETED:
04:50 PM
ALLEGATION(S):
1
2
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8
9
Staff are not providing skilled professional to care for resident's tracheostomy.
Staff are not dispensing medication as needed.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Teresa Camara and Erica Mosley conducted an initial complaint visit. LPAs were joined by North Los Angeles Regional Center (NLARC) Quality Assurance Specialist (QAS) Lisseth Carrillo. LPAs initially met with the staff LVN. Program Administrator Laurie Hernandez arrived at the facility at 12:30 p.m. LPAs explained the reason for the visit.

During today’s visit LPAs conducted a physical plant tour at 11:00 a.m. LPAs conducted interviews with staff starting at 10:55 a.m. LPAs reviewed medications and documents starting at 11:08 a.m. During a previous visit on 8/30/2023, LPA Camara met with the house manager and requested the manager email records to LPA once they were located.

(continued on LIC9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20230830100407
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ELWYN NC - BABCOCK
FACILITY NUMBER: 198601809
VISIT DATE: 08/15/2024
NARRATIVE
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(continued from LIC9099A)

During today's visit, LPAs gathered documentation which showed on 8/24/2023, when Client 1 (C1) returned from the hospital, two different respiratory therapists visited the facility, conducted a review of C1's needs for supplies, and assisted C1. Other documentation showed respiratory therapists were at the facility during C1's brief stay (8/24/2024 - 8/30/2024) at the facility after their hospitalization. C1 returned to the hospital on 8/30/2023 and has not returned to the facility since that time. Based on the documentation and interviews, the allegation Staff are not providing skilled professional to care for resident's tracheostomy is deemed Unsubstantiated at this time.

During today's visit, LPAs gathered information regarding C1's medication administration for the month of August 2023. Based on these documents, it appears C1's medications were give as prescribed. Therefore, the allegation Staff are not dispensing medication as needed is deemed Unsubstantiated at this time.

Exit interview conducted and report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5