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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601809
Report Date: 03/13/2025
Date Signed: 03/13/2025 01:27:09 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
03/11/2025 and conducted by Evaluator Erica Mosley
COMPLAINT CONTROL NUMBER: 29-AS-20250311120154
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:
03/13/2025
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Eivet Nazlou, LVN / House Manager
Laurie Hernandez, Administrator, 		TIME COMPLETED:
01:35 PM
ALLEGATION(S):
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Staff provided client extra fluid without a physician's order
Staff did not ensure client records were complete
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Erica Mosley conducted an initial 10-day complaint visit to investigate the above allegations. Upon arrival at 9:35 a.m. LPA knocked on the door and rang the doorbell a few times. It was clear no one was home. At 9:45 a.m. LPA called the Administrator, Laurie Hernandez to inform the reason for the visit and was advised that the staff had taken the clients to an appointment and would be back around lunch time. Administrator, Laurie Hernandez stated she would head over. At 12:11 p.m. LPA Mosley met with the house Manager / LVN Eivet Nazlou. The reason for the visit was explained. The Administrator Laurie Hernandez arrived at 12:24 p.m. The reason for the visit was explained.

Entrance interview conducted.

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: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
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 4
Control Number 29-AS-20250311120154
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: 03/13/2025
NARRATIVE
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(PAGE 2) REPORT CONTINUED FROM LIC 9099...

On 3/10/2025, the Department received a complaint regarding the following allegations, Staff provided client extra fluid without a physician's order and Staff did not ensure client records were complete. LPA and staff 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.

During today’s visit, at 12:14 p.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 12:36 p.m. conducted a file review and obtained copies of pertinent documents relevant to the investigation.



On the allegation Staff provided client extra fluid without a physician's order, it is the concern of the Reporting Party (RP) that the facility staff, Staff #1 (S1) provided Client #1 (C1) with extra fluids without a physician’s order. To investigate this complaint, LPA reviewed the facilities protocols, policies, procedures, and orders as they pertain to physician's orders and conducted a file review for C1. Review of the facilities protocols, policies, procedures, and orders as they pertain to physician's orders revealed that “Policy #600 Nutrition and Hydration Policy and Procedures. V-Encouraging and Restricting Fluid. Nursing must verify that there are physician orders for a particular procedure and follow the health care plan to assess any special needs. Only orders prescribed by the doctor can be executed. All correspondence with the physician must be documented and during endorsements must be reviewed with next shift.” File review for C1 revealed that S1 failed to adhere to the physician’s order and provided C1 with more than what was prescribed. On 10/01/2024 S1 provided extra fluid for urine output. This was never prescribed by the doctor. Based on information obtained, reviewed, file review and a credible witness there is sufficient evidence to support the allegation occurred. Therefore, the allegation of Staff provided client extra fluid without a physician's order is deemed substantiated at this time.

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

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20250311120154
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: 03/13/2025
NARRATIVE
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(PAGE 3) REPORT CONTINUED FROM LIC 9099-C PAGE 2...

On the allegation the Staff did not ensure client records were complete, it is the concern of the Reporting Party (RP) that facility staff did not ensure C1’s records were complete and accurate. To investigate this complaint, LPA reviewed the facilities protocols, policies, procedures as they pertain to documentation for client records and conducted a file review for C1. Review of the facilities protocols, policies, procedures as they pertain to documentation for client records revealed that “Policy #300 Expectation of High-Quality Documentation - requires factual, accurate, complete, concise, current, and organized”. File review for C1 revealed that nursing notes were not consistent in what information was given. Handwriting of some notes were ineligible which made it very difficult to read. Information should be placed in the same place on each note for consistency. Furthermore, Nursing notes were found to be lacking details of what care was given to C1 throughout each shift. Based on information obtained, reviewed, file review and a credible witness there is sufficient evidence to support the allegation occurred. Therefore, the allegation Staff did not ensure client records were complete is deemed substantiated at this time.

The following deficiencies 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: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20250311120154
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: 03/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/21/2025
Section Cited
CCR
80072(a)2
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80072 (a) 2 Personal Rights
..., each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful … to meet his/her needs. This requirement was not met as evidenced by:
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Elwyn Babcock Administration will ensure staff adhere to Nursing Policies & Procedures (P&P) at all times by conducting a training on Nursing Policy #300, #600 and #1800 by POC due date.
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Based on record review, the licensee did not comply with the section cited above when S1 failed to adhere to the physician’s order and provided C1 with more than what was prescribed.
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Type B
03/21/2025
Section Cited
CCR
80070(a)
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80070 (a) Client Records
The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client. This requirement was not met as evidenced by:
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Elwyn Administration will train all staff (licensed staff and DSPs) on appropriate documentation in accordance with the home’s P&P and competencies. Send CCLD training materials by POC due date
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Based on record review, the licensee did not comply with the section cited above as the Nursing notes were found to be lacking details of what care was given to C1 throughout each shift.
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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: 03/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4