<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602217
Report Date: 05/06/2024
Date Signed: 05/06/2024 02:12:01 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/03/2024 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240503133047

FACILITY NAME:ELWYN CALIFORNIA - NOVARROFACILITY NUMBER:
198602217
ADMINISTRATOR:VERNON VAN RODRIGUEZFACILITY TYPE:
735
ADDRESS:1027 NOVARRO STTELEPHONE:
(626) 699-1889
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY:4CENSUS: 4DATE:
05/06/2024
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Martin SyTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not meet resident’s dental care needs
Staff mismanaged resident’s medication
Staff do not ensure client has appropriate amount of clothing.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Christine Wong conducted an Initial 10-Day complaint investigation in regards to the above mentioned allegations. LPA discussed the purpose of the visit with Administrator Martin Sy and assisted with the visit.

The investigation consisted of the following: LPA conducted a health & safety check of clients in care. LPA observed a sufficient supply of perishable and non-perishable foods. LPA did not observe any immediate health and/or safety concerns for clients in care. The staff also provided LPA copies of requested documents. The following documents were obtained: Client#1 (C1) file documents include: face sheet, physician order, dental visit information, medical visit information and all four clients' P&I Ledger . LPA also interviewed administrator, three staff (S2-S4) and four clients (C1-C4) and reviewed clients' mediation and P&I Ledge and tour the facility including client's room/closet.

(See LIC9099C for continuation)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20240503133047
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ELWYN CALIFORNIA - NOVARRO
FACILITY NUMBER: 198602217
VISIT DATE: 05/06/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The investigation revealed of the following: Allegation of "Staff did not meet resident’s dental care needs" It's alleged that client's dental care has been neglected. LPA interviewed two out of two clients and all denied the allegation and reported staff did take them to see dentist and they both just had their recent dental check up. LPA also reviewed client's dental record especially for C1, C1's last dental check up was on 8/16/23 and other clients in the facility also has the updated dental check up for last year.

Allegation of "Staff mismanaged resident’s medication " It's alleged that staff manipulated client's controlled medicine. LPA interviewed clients and indicated staff are on top of their medication and everything is okay for their medication. LPA interviewed staff and reported C1's controlled medicine (Lorazepam 1mg) PRN medication and had already discontinued on 10/10/23 due to client did not really take that medication. Staff reported C1 probably took once since prescribed and the medication even created more behaviors for C1. After the physician discontinued the Lorazepam, the physician never replaced any anti-depressant medicine for C1. LPA also reviewed other client's Medication Administration Records (MARs) and all clients' medication are seemed updated and accurate.

Allegation of " Staff do not ensure client has appropriate amount of clothing. " It's alleged that client does not have much clothes(underwear) and all his current clothes are "hand me downs". LPA interviewed clients and reported they have adequate clothes for them to wear. LPA interviewed staff and denied the allegation and reported no clients ever complained they have no clothes in the facility. LPA also toured client's closet and each client has ample clothing in their closet including underwear.

Based on the recorded review, interviews conducted with staff and clients, 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 allegations are UNSUBSTANTIATED.

Exit interview conducted with Administrator Martin Sy and a copy of this record provided.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3