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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601809
Report Date: 09/21/2022
Date Signed: 09/21/2022 03:40:41 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
09/14/2022 and conducted by Evaluator Elsie Campos
COMPLAINT CONTROL NUMBER: 29-AS-20220914181052
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:
09/21/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:House Manager- Faith NdagwaTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Resident's medication is not properly stored.
Staff do not meet training requirements.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elsie Campos conducted an unannounced visit for the above allegations. The LPA spoke with House Manager Faith Ndagwa and explained the reason for the visit. Administrator Hazel Gatan was not present, however LPA spoke to the Administrator over the phone.

Today, the LPA conducted a brief facility tour at 2:05 p.m., interviewed staff at 2:20 p.m. and 2:25 p.m.

Regarding the allegation: Staff do not meet training requirements: it was alleged that upon review of personnel records this facility failed to ensure personnel obtained First Aid and CPR certification in accordance with Elwyn’s Program Design.

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

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
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 3
Control Number 29-AS-20220914181052
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: 09/21/2022
NARRATIVE
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A credible witness identified that twelve (12) of twenty-two (22) staff had completed their First Aid and CPR certification online with no hands-on skill validation for the certification. Interviews and documentation review confirmed that the required training was not met. Staff interviews further confirmed that CPR training was completed online and not in person to due to COVID. It is required for facility staff to complete in person First Aid and CPR training. The house manager indicated that in person training was scheduled and a skilled trainer would be coming to the facility. Based on the information obtained, this allegation is deemed Substantiated at this time.

Regarding the allegation: Resident’s medication is not properly stored: it was alleged that a medication cart was unlocked and unattended and a mini refrigerator containing medications was also identified to be unlocked. Upon the discovery of the unlocked medications, staff immediately locked and secured the medications. On a subsequent visit a mini refrigerator containing consumer medication was found to be unlocked by a credible witness. During a brief facility tour, House Manager identified the medication cart and medication refrigerator at which time LPA Campos confirmed it was locked. Interviews confirmed that the medication cart had been momentarily been left unlocked at the time of the visitors visit and that the medication refrigerator also did not have an secured lock at the time of observation. The house manager indicated that the medication refrigerator did not have an appropriate lock but has since been fixed. 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: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20220914181052
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: 09/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/23/2022
Section Cited
CCR
80075(k)(1)
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80075 Health Related Services (k)(1) The following requirements shall apply…Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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The Administrator agreed to do the following:
1. Complete a plan of action detailing the facilities steps to ensure that medications remain locked at all times and submit to CCL no later than 9/23/22.
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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 client medications were unlocked which poses an immediate health risk to persons in care.
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2. Client medications were locked and secure at the time of the visit.
Type B
09/23/2022
Section Cited
CCR
80075(f)
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80075 Health Related Services (f) staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This requirement is not met as evidenced by:
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The Administrator agreed to the following:
1. Schedule staff to complete in person First Aid and CPR training and provide a copy of the updated first aid certificates to CCL no later than 9/23/2022.
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Based on interviews and record review, licensee did not ensure that 12 out of 22 direct care staff have current hands-on first aid and CPR training poses a potential health and safety risk to residents in care.
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2. Provide a list of any staff who do not complete training and indicate a date of completion.
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: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3