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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601809
Report Date: 03/29/2022
Date Signed: 03/29/2022 06:55:50 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
03/22/2022 and conducted by Evaluator Elsie Campos
COMPLAINT CONTROL NUMBER: 29-AS-20220322102808
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: 4DATE:
03/29/2022
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Eivet Azizian and Sumaiya NaluwuTIME COMPLETED:
07:00 PM
ALLEGATION(S):
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Staff did not ensure the clients had a physician visit while in care
Staff did not meet the minimum qualifications required
Failure to follow the Plan of Operation regarding staffing hours
Staff failed to receive required 20 hours of continuing education
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elsie Campos conducted an unannounced visit for the above allegations. The LPA spoke with LVN Eivette Azizian and LVN Sumaiya Naluwu and explained the reason for the visit. Today, the LPA interviewed staff at 2:40 p.m., 2:50 p.m., 3:50 p.m., conducted a brief facility tour at 3:00 p.m., reviewed records between 3:10 p.m. and 5:26 p.m.

Regarding the allegation: Staff did not ensure the clients had a physician visit while in care: it was alleged that this facility was not meeting the client’s needs in scheduling a 60-day physician visit as required. To investigate this allegation, the LPA reviewed relevant documentation and conducted staff interviews and found that Resident #1, Resident #2 and Resident #3 have not had a physician visit since December 23, 2021.

Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
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-20220322102808
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: 03/29/2022
NARRATIVE
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R1, R2 and R3 had a physician visit on March 9th, 2022 and telephone physician visit on 3/25/22 with a potential new Primary Care Physician (PCP). Staff indicated that numerous efforts to ensure that appointments were being scheduled timely were attempted but proved to be unsuccessful as calls were not returned or emails were not responded to by the physician’s office. The house manager confirmed that the residents were late for their 60-day physician visits and have since met with the physician to ensure compliance. Therefore, based on the interviews and documentation review , it was confirmed that the required physician visits were not met and this allegation is deemed Substantiated at this time.

Regarding the allegation: Staff did not meet the minimum qualifications required: it was alleged that this facility was not meeting the required Direct Support Professional training (DSP I) and/or (DSP II). Interviews and documentation review confirmed that the required DSP training was not yet met. Staff interviews confirmed that training was in process and not completed. Records review confirmed that Staff #1, Staff #2 and Staff #3 had not completed all DSP training. Staff #1 completed DSP I training on 3/18/2022 and is now eligible to schedule DSP II training. Staff #2 is overdue for DSP I and DSP II training and records reflect that DSP I was last completed on 1/31/2020 and DSP II was last completed 3/6/2020. Staff #3 completed DSP I training on 2/8/2020 and DSP II training on 12/17/2021. Staff #4 and Staff #5 do not have updated DSP training information available. The house manager indicated that staff training was assumed to be completed and has not been reviewed, as the house manager came on board in October 2021. Based on the information obtained, this allegation is deemed Substantiated at this time.

Continued on LIC 9099-C
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20220322102808
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: 03/29/2022
NARRATIVE
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Regarding the allegation: Failure to follow the Plan of Operation regarding staffing hours: it was alleged that this facility was not meeting the required Registered Nursing (RN) hours. The facility experienced a deficiency of RN staffing hours from January 24th, 2022 through February 6th, 2022, as there needs to be a registered nurse on duty a minimum of six hours per day, 5 days week totaling a minimum of 30 hours of RN hours per week. During that week, the RN hours were deficient a total of 7.47 hours. The house manager confirmed there was a staffing shortage and will be working with the administrator to implement a plan to ensure sufficient hours. Based on the information obtained, this allegation is deemed Substantiated at this time.

Regarding the allegation: Staff failed to receive required 20 hours of continuing education: it was alleged that the facility was not meeting the required hours of continuing education. Interviews and documentation review confirmed that the required hours were not yet met. Records review confirmed that S1 completed the required continuing education hours on 3/18/22. Records review confirmed that S3 completed the required continued education on 12/17/2021. The LPA reviewed in service training records from January 2022 through March 2022 and confirmed that S2, S3, S4 and S5 had completed a total 10 hours of continued education so far. Staff confirmed that training is ongoing, and hours are completed during in service training's. 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.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20220322102808
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: 03/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/08/2022
Section Cited
CCR
85078(a)(1)
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85078(a)(1) Responsibility for Providing Care and Supervision (a) In addition to Section 80078 ...(1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs. This requirement was not met as evidenced by:
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The Administrator agreed to the following:
Submit a Plan of Action, detailing the efforts in ensuring client’s needs and services are being met. This includes scheduling doctor’s appointments within required time frames. To CCL no later than 4/8/2022.
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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 ensure that clients are meeting with physician timely, which poses an immediate health and safety risk to clients in care.
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Type B
04/08/2022
Section Cited
CCR
80065(f)
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80065(f) Personnel Requirements 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...This requirement was not met as evidenced by:
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The Administrator agreed to the following:
Submit a Plan of Action, detailing the efforts in meeting staffing and training requirements to CCL no later than 4/8/2022.
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Based on interview and record review, the licensee did not comply with the section cited above, as staff did not meet the required 20 hours of continuing education required by the department, which poses an immediate health and safety risk to clients 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: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20220322102808
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: 03/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/08/2022
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 30 hours per week.
2. Submit a Plan of Action, detailing the efforts in meeting staffing requirements and RN required hours to CCL no later than 4/8/22.
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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 nursing hours a minimum of 30 hours of registered nursing hours a week, which poses an immediate health and safety risk to clients in care.
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This is a repeat violation. Civil penalties assessed.
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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: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5