198601809-10-4-2023-29-AS-KHEN-CWVW22-20231023165337

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601809
Report Date: 10/04/2023
Date Signed: 10/04/2023 11:50:30 AM

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
09/27/2023 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20230927154352

FACILITY NAME:	ELWYN NC - BABCOCK		FACILITY NUMBER:	198601809
ADMINISTRATOR:	HAZEL LAZAGA GATAN		FACILITY TYPE:	734
ADDRESS:	5149 BABCOCK AVE		TELEPHONE:	(818) 287-5416
CITY:	VALLEY VILLAGE	STATE: CA	ZIP CODE:	91607
CAPACITY:	5	CENSUS: 4	DATE:	10/04/2023
		UNANNOUNCED	TIME BEGAN:	09:06 AM
MET WITH:	Faith Ndegwa - House Manager		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility is unkempt
Facility did not have smoke detectors installed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced initial complaint visit at the facility today. At 9:06 a.m., the LPA met with staff and explained the reason for the visit. The Administrator, Vernon Rodriguez was not available during the time of the visit, however House Manager, Faith Ndegwa is authorized to sign the report.

During today’s visit, between 9:20 a.m. and 9:33 a.m., the LPA conducted interviews with three (3) staff. At 9:34 a.m., the LPA along with the House Manager conducted a physical plant tour. At 9:41 a.m., the LPA obtained copies of pertinent documents. At 11:35 a.m., fire alarm/ carbon monoxide detectors were tested and functioned properly.

Continued on LIC 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230927154352

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: 10/04/2023

NARRATIVE

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Regarding the allegation: Facility is unkempt. On 09/27/2023, the department received a complaint alleging that the facility’s overall cleanliness was lacking. On 08/29/2023, a credible witness observed and noted the following at the facility: dust build up and cobwebs around the facility, and the oven covered with grease. During today’s visit, the LPA observed staff cleaning clients’ rooms and the kitchen. The LPA observed the facility to be relatively clean and sanitary. Staff interviews revealed that staff are constantly cleaning and sanitizing the facility throughout their shift. A copy of staff house duties was provided to the LPA during the time of the visit. Based on the observation from a credible witness, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated.

Regarding the allegation: Facility did not have smoke detectors installed. On 09/27/2023, the department received a complaint alleging that the facility’s bedrooms did not have smoke detectors installed. On 08/29/2023, a credible witness observed and noted the following at the facility: client bedrooms did not have smoke detectors installed and appeared that the detectors were removed. On 08/29/2023, once staff were made aware of the missing smoke detectors, staff re-installed the smoke detectors. During today’s visit, the LPA observed smoke detectors inside all client bedrooms. Staff interviews revealed that a few months ago, a work order was placed to replace the smoke detectors and that maintenance took a while to replace them. Based on the observation from a credible witness, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8 and California Health and Safety Code the following deficiencies were observed and cited during the visit (See 9099-D).

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230927154352

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: 10/04/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/04/2023 Section Cited CCR 80020	1 2 3 4 5 6 7	80020 Fire Clearance (a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	On 08/29/2023, the smoke detectors were re-installed. During today’s visit, the LPA confirmed that the client bedrooms had smoke detectors. Plan of correction met.
	8 9 10 11 12 13 14	Based on observation from a credible witness, the licensee did not comply with the section cited above as smoke detector in the client rooms were missing at the time of the visit of 08/29/2023 which poses an immediate health and safety risk to persons in care.	8 9 10 11 12 13 14
Type B 10/06/2023 Section Cited CCR 80087(a)	1 2 3 4 5 6 7	80087 (a) Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	During today’s visit, the LPA observed the facility to be clean and sanitary. The Administrator stated that they will submit a plan on how the facility will ensure that staff assigned to cleaning duties are completing their tasks by due date.
	8 9 10 11 12 13 14	Based on observation from a credible witness, the licensee did not comply with the section cited above as the facility was observed to have dust build up, cobwebs and grease inside the stove, which poses a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14

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: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

LIC9099 (FAS) - (06/04)

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