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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601809
Report Date: 01/24/2023
Date Signed: 01/24/2023 03:53:35 PM

Unsubstantiated


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
07/11/2022 and conducted by Evaluator Elsie Campos
COMPLAINT CONTROL NUMBER: 29-AS-20220711153411
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: 3DATE:
01/24/2023
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Vernon Rodriguez-AdministratorTIME COMPLETED:
04:05 PM
ALLEGATION(S):
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Staff speak loudly in their language while caring for residents
Staff leave residents unattended while napping
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elsie Campos conducted an unannounced subsequent complaint visit at the facility regarding the above allegations. The LPA met with Administrator Vernon Rodriguez and explained the reason for the visit.

On 07/20/2022, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced visit at 3:45 p.m. to investigate the above allegations. The LPA and the House Manager (HM) toured the facility, and briefly spoke with staff, and interviewed the HM from 4:15 p.m. to 4:35 p.m. The LPA requested copies of staff's roster, Attendance sheets, and resident roster and issued a needs further prior to issuing final findings. On 9/23/2022 LPA Campos conducted a facility tour at 10:30 a.m., reviewed documents at 11:00 a.m., interviewed staff at 11:05 a.m., 11:15 am. and 11:22 a.m. LPA requested Administrator to submit additional documents relevant to the case and issued a needs further prior to issuing final findings.
Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023
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-20220711153411
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: 01/24/2023
NARRATIVE
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During today’s visit the LPA collected staff and resident rosters at 11:35 a.m., conducted a medication audit for (3) three out of (3) residents at 1:03 p.m., interviewed resident at 11:37 a.m., interviewed staff at 11:40 a.m., 12:10 p.m., 12:43 p.m. 2:25 p.m., 2:35 p.m. and 3:25 p.m.

Regarding the allegation: Staff speak loudly in their language while caring for residents

The complainant’s concern was that the staff constantly speak in their language and loudly while caring for the residents. Interview with the Administrator confirmed that it has been communicated to staff to ensure that communication is clear, and that when speaking amongst each other it is done so that everyone can understand what is being said, so there is no confusion among staff. The Administrator further denied that staff speak loudly in front of the residents in their language. Interviews with staff indicated that staff do speak in their language amongst each other however it always done away from the residents. Interviews with residents did not reveal any concerns as all residents are non-verbal. Based on the information provided, although the facility has had moments where staff may speak in their language, it is not an everyday occurrence and it does not happen with the residents present.. At this time there is insufficient evidence to support the claim that staff speak loudly in their language while caring for residents. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Staff leave residents unattended while napping

The complainant’s concern was that Staff #1 (S1) and Staff #2 (S2) take naps when the other staff leave for the day during the afternoon shift. The complainant indicates that this leaves residents unattended which resulted in Resident #1 (R1) swallowing a gauze dressing. R1 is known to scratch around their G-Tube and chewing on their clothes. An interview with staff indicated that R1 wears a binder over their G-Tube preventing them from scratching off any tape or gauze protecting the area. Staff interviews denied allegations that staff leave residents unattended while napping. Interviews revealed that if staff take a nap it is done on their designated breaks in the designated break area or away from the facility. All breaks are communicated amongst staff to ensure that residents are not left unattended. At this time there is insufficient evidence to support the claim that staff speak loudly in their language while caring for residents. This allegation is deemed Unsubstantiated at this time.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
07/11/2022 and conducted by Evaluator Elsie Campos
COMPLAINT CONTROL NUMBER: 29-AS-20220711153411

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: 3DATE:
01/24/2023
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Vernon Rodriguez-AdministratorTIME COMPLETED:
04:05 PM
ALLEGATION(S):
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Medication errors
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elsie Campos conducted an unannounced subsequent complaint visit at the facility regarding the above allegations. The LPA met with Administrator Vernon Rodriguez and explained the reason for the visit.

On 07/20/2022, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced visit at 3:45 p.m. to investigate the above allegations. The LPA and the House Manager (HM) toured the facility, and briefly spoke with staff, and interviewed the HM from 4:15 p.m. to 4:35 p.m. The LPA requested copies of staff's roster, Attendance sheets, and resident roster and issued a needs further prior to issuing final findings. On 9/23/2022 LPA Campos conducted a facility tour at 10:30 a.m., reviewed documents at 11:00 a.m., interviewed staff at 11:05 a.m., 11:15 am. and 11:22 a.m. LPA requested Administrator to submit additional documents relevant to the case and issued a needs further prior to issuing final findings.
Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20220711153411
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: 01/24/2023
NARRATIVE
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During today’s visit the LPA collected staff and resident rosters at 11:35 a.m., conducted a medication audit for (3) three out of (3) residents at 1:03 p.m., interviewed resident at 11:37 a.m., interviewed staff at 11:40 a.m., 12:10 p.m., 12:43 p.m. 2:25 p.m., 2:35 p.m. and 3:25 p.m.

Regarding the allegation: Medication errors
The complainant’s concern was that Staff #1 (S1) had medication errors. The LPA conducted a medication audit for (3) three out of (3) residents. A staff record review determined that S1 is no longer scheduled at this facility. However, it was alleged that medication errors were happening at the facility and being covered up by the administration. During today’s visit, the LPA conducted an audit on (3) three of (3) resident medication records and found errors in medication logging. Prescription numbers, doctors information, issued dates and expiration dates did not match bubble packs on (3) occasions for Resident #2 (R2). The LPA further found that Resident #3 (R3) had Phenonarbital refilled on 1/11/23 (1) one tablet morning and evening however morning and evening bubble packs were started on different days with no explanation or documentation indicating the discrepancy. The Phenonarbital evening pack was started on 1/13/2023 and the morning pack was stared on 1/18/2023. When speaking to the on duty Licensed Vocational Nurse (LVN) there was no explanation given indicating why the medication given did not match and there were no notes on record indicating the cause of the discrepancy. All medication logs were signed off, indicating that all residents had been assisted with receiving their medication. Interviews revealed that staff are trained on medication and medications go through a secondary verification before being issued to the resident. However, based on the information obtained, there is sufficient evidence to support the claim that there are medication errors. This allegation is deemed Substantiated at this time.

Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiencies are
cited: (Refer to LIC 9099-D). Exit interview Conducted. Complaint was also discussed with Administrator.
Appeal Rights Discussed. A Copy of the Report Issued.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20220711153411
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: 01/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/26/2023
Section Cited
HSC
80075(k)(7)
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80075(k)(7) Health Related Services The following requirements shall apply to medications which are centrally stored: The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications…This requirement is not met as evidenced by.
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The Administrator agreed to do the following:
1. Schedule a training regarding 80075 Health Related Services. Verification of scheduled training with the trainer’s credentials will need to be submitted by 1/26/2022 and completion of training must be submitted no later than 2/3/2023.
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Based on observation, the licensee did not comply with the section cited above, as medication errors were observed for two (2) out of three (3) clients, 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: 01/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5