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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601809
Report Date: 04/03/2024
Date Signed: 04/04/2024 09:35:24 AM

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
03/27/2024 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20240327083659
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:
04/03/2024
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Eivette Azizian, LVNTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility is not adhering to resident(s) Admission Agreement(s).
Staff are not ensuring that resident(s) medical needs are being met while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Zabel Chochian conducted an unannounced visit for the above allegations. Upon arrival LPA met with staff Kenneth Brooks and introduced self and reason for visit was stated. LPA toured the facility with staff at approximately 11:45am. LPA was introduced to three other staff present at the facility. LVN Eivette Azizian contacted Administrator Vernon Rodriguez and reason for LPA's visit was discussed. Today, the LPA interviewed staff from 12pm-12:30pm. and reviewed facility records between 12:30pm-1pm. Following is a summary of the allegations and finding:

Regarding the allegation: Staff are not ensuring that resident(s) medical needs are being met while in care. It was alleged that the 60-day physician visits were not completed on-time for three (3) out of four (4) residents in care. Information provided by credible witness, interview conducted with Administrator Vernon Rodriquez and resident records reviewed for resident #1 (R1) R2 and R3 revealed that the last 60-day physician visit for residents R1 and R2 were on 10/5/23, 11/16/23, 12/18/23 and 2/22/24. Both residents R1 and R2 were taken to Studio City Urgent Care for doctor rounds after 67 days on 2/22/24. (Continue to LIC9099c)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
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-20240327083659
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: 04/03/2024
NARRATIVE
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The last 60-day physician visits for resident R3 were on 10/19/23, 11/9/23, 12/14/23 and 2/23/24. R3 was seen by physician on 2/23/24 after 72 days. Based on the information obtained, this allegation is deemed Substantiated at this time.

Regarding the allegation: Facility is not adhering to resident(s) Admission Agreement(s): It was alleged that this facility was not adhering to resident(s) Admission Agreement as it states that the facility shall ensure the resident(s) remain under the care of a physician at all times and is examined by the primary care physician at least once every 60 days, or more often if required by the resident's individual health care plan. Based on records review and interview conducted with Administrator, it was confirmed that three (3) out of four (4) residents were not seen by a physician at least once every 60 days. Facility did not adhere to residents admission agreement as three (3) out of four (4) residents were not examined by their primary care physician at least once every 60 days. 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 cited: (Refer to LIC 9099-D). Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20240327083659
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: 04/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/04/2024
Section Cited
HSC
85078(a)(1)
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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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Administrator Vernon Rodriguez agreed to the following: Submit a Plan of Action, detailing the efforts in ensuring client’s needs and services are being met, including but not limited to adhering to residents admission agreement, scheduling doctor’s appointments within required time frames etc.
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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 three (3) out four (4) residents are meeting with physician timely, which poses an immediate health and safety risk to residents in care.
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HSC
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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: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3