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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601809
Report Date: 12/06/2024
Date Signed: 12/06/2024 04:42:01 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
12/04/2024 and conducted by Evaluator Erica Mosley
COMPLAINT CONTROL NUMBER: 29-AS-20241204172138
FACILITY NAME:ELWYN NC - BABCOCKFACILITY NUMBER:
198601809
ADMINISTRATOR:LAURIE HERNANDEZFACILITY TYPE:
734
ADDRESS:5149 BABCOCK AVETELEPHONE:
(818) 287-5416
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY:5CENSUS: 2DATE:
12/06/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Jon O’ Campo - Home RN TIME COMPLETED:
04:50 PM
ALLEGATION(S):
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Staff does not have sufficient training
Insufficient Staffing
Client records are not accurate
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Erica Mosley conducted a joint visit with North Los Angeles County Regional Center (NLACRC), Quality Assurance Specialist (QAS) Lisseth Carrillo conducted an initial 10-day complaint visit to investigate the above allegations. Upon arrival approx at 10:15 am, LPA Mosley and QSA Carrillo were greeted by Staff, Jon O’ Campo - Home RN and called the Administrator to inform them of the visit. The Administrator Laurie Hernandez was unable to attend and designated staff to sign the report. The reason for the visit was explained. Entrance interview conducted.

On 12/04/2024, the Department received a complaint regarding the following allegations, Staff does not have sufficient training, Insufficient Staffing, and Client records are not accurate. LPA along with QAS toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards and facility is in compliance with Title 22 Regulations.

Report continued on LIC 9099-C PAGE 2...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
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-20241204172138
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: 12/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/27/2024
Section Cited
CCR
80070(a)
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(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This requirement is not met as evidenced by:
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Administrator will have home RN in review IHCP of R1 and R3 to ensure health assessments and conditions have clear and accurate information and appropriate interventions for continuity of care and support by home staff and IHCP team
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Based on record review, the licensee did not comply with the section cited above as two (2) clients health assessments and conditions did not have clear and accurate information and appropriate interventions which poses a potential health and safety risk to persons in care.
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members and send proof for the update to CCLD by POC due date.
Type B
12/27/2024
Section Cited
CCR
80065(f)(3)
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(f) All personnel shall be given on-the-job training or shall have related experience ... in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. (3) Provision of client care and supervision, including communication.
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Administrator will have home RN review IHCP for R1 and R3 to ensure appropriate competency training for licensed and unlicensed staff to meet residents’ needs and send proof of the update to CCLD by POC due date.
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Based on record review, the licensee did not comply with the section cited above as staff do not have appropriate competency training for licensed and unlicensed staff to meet residents’ needs.
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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: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20241204172138
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: 12/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/20/2024
Section Cited
CCR
80065(f)(6)
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(f) All personnel shall be given on-the-job training or shall have related experience ... in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. (6) Availability of community services and resources.
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Administrator will conduct Staff in-service or programming related to community services and resources particularly in related to community integration and activities that will help meet the residents IPP goal and social needs and send proof to CCLD by POC due date.
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Based on record review, the licensee did not comply with the section cited above as staff do not have appropriate competency training for licensed and unlicensed staff to meet residents’ needs.
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Type B
12/20/2024
Section Cited
CCR
85065(f)
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(f) The licensee shall ensure that all direct services to clients requiring specialized skills are performed by personnel who are licensed or certified to perform the service. Based on record review for the licensee did not comply with the section cited as The name of the individual health care plan team member
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Administrator will conduct an audit and ensure that clients have an alternate IHCP team member, preferably another RN, identified in the IHCP and send proof of the updates to CCLD by POC due date.
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 and an alternate designee, who is responsible for day-to-day monitoring of the consumer's health care plan and ensuring its implementation as written both shall be RN's for R1 and R2 requires an alternate identified on IHCP.
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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: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20241204172138
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: 12/06/2024
NARRATIVE
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(PAGE 2) REPORT CONTINUED FROM LIC 9099...
During today’s visit, at 10:36 a.m. LPA conducted a physical plant tour to ensure there are no immediate health and safety concerns and facility is in compliance with Title 22 Regulations, at 11:15 a.m. conducted an in-person interview with one (1) staff, at 11:32 a.m. conducted a file review, and obtained copies of pertinent documents relevant to the investigation.
On the allegation Staff does not have sufficient training, it is the concern of the Reporting Party (RP) that the facility staff does not have a description of a plan for providing training required for all direct care personnel to meet individuals' needs and Staff in-service or programming related to community services (and implement health care plans) for Resident #1 (R1) and resources particularly in related to community integration and activities that will help meet the residents IPP goal and social needs. To investigate this complaint, LPA conducted an audit on the facilities in service trainings and a file review including R1. Audit revealed that the facility has not conducted staff in-service training or programming related to community services and resources, particularly in relation to community integration and activities that will help meet the residents IPP goal and social needs posing a potential health and safety risk to clients in care. Audit revealed that the facility does not have a description and plan for training and competency to meet health care needs for R1 and the use of APAP and oxygen saturation monitoring and use specific to R1. Based on information obtained, audit preformed and a credible witness there is sufficient evidence to support the allegation occurred. Therefore, the allegation of Staff does not have sufficient training is deemed substantiated at this time.
On the allegation the facility has Insufficient Staffing, it is the concern of the Reporting Party (RP) that the facility is not sufficiently staffed. To investigate this complaint, LPA conducted a file review including R1 and R2. Based on file review in the name of the Individual Health Care Plan ( IHCP) team member, and an alternate designee, who is responsible for day-to-day monitoring of the consumer's health care plan and ensuring its implementation as written. R1 should have both health care plan team members listed as Registered Nurses (RN’s) however R1 only has one (1) RN listed posing a potential health and safety risk to clients in care. File review on Resident #2 (R2) should have an alternate designee, who is responsible for day-to-day monitoring of the consumer's health care plan however only one (1) RN, IHCP team member is identified responsible for the day-to-day monitoring of the resident’s health care plan and ensuring implementation.

Report continued on LIC 9099-C PAGE 3...
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20241204172138
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: 12/06/2024
NARRATIVE
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(PAGE 3) REPORT CONTINUED FROM LIC 9099-C PAGE 2...
No alternate designee, who is responsible for day-to-day monitoring of the consumer's health care plan is identified on recent IHCP posing a potential health and safety risk to clients in care. Based on information obtained, audit preformed, file review and a credible witness there is sufficient evidence to support the allegation occurred. Therefore, the allegation of the facility has Insufficient Staffing is deemed substantiated at this time.
On the allegation the Client records are not accurate, it is the concern of the Reporting Party (RP) that the client’s records are not accurate including R1 and Resident #3. To investigate this complaint, LPA conducted a file review including R1 and R3. Based on file review R1, Under Obstructive Sleep Apnea diagnosed on 9/24/24, the nursing interventions listed for this condition were not related to sleep apnea and should be revised posing a potential health and safety risk to clients in care. File review for R3 revealed that Under Nutrition, less body requirement condition, the interventions included “Give diet and fluids as ordered by MD via GT”. However, resident eats by mouth. The health assessments and conditions do not have clear and accurate information with appropriate interventions for continuity of care and support by home staff and IHCP team members posing a potential health and safety risk to clients in care. Based on information obtained, audit preformed, file review and a credible witness there is sufficient evidence to support the allegation occurred. Therefore, the allegation of Client records are not accurate is deemed substantiated at this time.

The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and / or California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. Report was reviewed. A copy and appeal rights were issued.


SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5