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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601809
Report Date: 04/28/2023
Date Signed: 04/28/2023 10:04:02 AM

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
05/03/2021 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20210503112409
FACILITY NAME:ELWYN NC - BABCOCKFACILITY NUMBER:
198601809
ADMINISTRATOR:JOSEPH TIGHEFACILITY TYPE:
734
ADDRESS:5149 BABCOCK AVETELEPHONE:
(818) 287-5416
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY:5CENSUS: 3DATE:
04/28/2023
UNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:Alexis CalicdanTIME COMPLETED:
10:10 AM
ALLEGATION(S):
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Resident sustained injuries while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit to the above facility. The purpose of today’s visit is to deliver findings for an investigation initiated by LPA Aja Richardson on 05/05/2021. At 9:39 a.m., the LPA met the staff and explained the reason for the visit. At 9:51 a.m., the LPA spoke with the Administrator, Vernon Rodriguez over the phone. The Administrator was unavailable during the time of the visit and authorized Licensed Vocational Nurse (LVN) Alexis Calicdan to sign the report.

During the initial visit on 05/05/2021, between 11:45 a.m. and 1:00 p.m., LPA Aja Richardson conducted a brief facility tour, interviewed staff, reviewed, and obtained pertinent documents. On 03/30/2023 at 3:04 p.m., LPA Peraldi conducted a telephonic interview with North Los Angeles County Regional Center (NLACRC) Nurse Consultant and requested pertinent documents. Additionally, on 03/30/2023 at 3:12 p.m., LPA Peraldi conducted a telephonic interview with the current Administrator. Continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
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 2
Control Number 29-AS-20210503112409
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: 04/28/2023
NARRATIVE
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Regarding the allegation: Resident sustained injuries while in care. On 05/03/2021, the Department received a complaint regarding Resident #1 (R1) being admitted to the Emergency Room (ER) with multiple wounds on 04/28/2021 from the facility Elwyn California Babcock Home. The complainant described the wounds to be on R1’s left hand, left side face redness, scars and a scar on the sacral. During the telephonic interview on 03/30/2023 conducted by LPA Peraldi, NLACRC Nurse Consultant explained that R1 was admitted to the facility, Elwyn California Babcock Home on 04/24/2021 with injuries/ wounds. The NLACRC Nurse Consultant stated that R1 already had the injuries prior to been admitted to the facility and that wound care was being provided and approved by NLACRC. The NLACRC Nurse Consultant provided LPA Peraldi with the following documents: R1’s Individual Planning Program (IPP) dated on 05/19/2021, R1’s wound care order dated 05/03/2021, R1’s Initial and Weekly Pressure Injury (PI) Progress Reporting Form dated 04/24/2021, and Incident Reports of R1’s ER visit dated 04/28/2021. On 04/24/2023, LPA Peraldi conducted a record review of R1’s documents provided by the NLCRC Nurse Constant. R1’s IPP confirmed that R1 was admitted to the Elwyn California Babcock Home with the following wounds and wound care orders: left hand pressure injury, sacral pressure sore, right upper arm and left ankle. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2