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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602217
Report Date: 06/11/2024
Date Signed: 06/11/2024 08:51:22 AM

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:
06/11/2024
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Julienna Barrera TIME COMPLETED:
09:05 PM
ALLEGATION(S):
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Staff hit resident with an object which resulted in injuries.
Staff used inappropriate form of punishment.
Staff falsified documents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wong conducted a subsequent visit to ascertain additional information regarding the above-mentioned allegation(s) and for the purpose of rendering the findings. LPA met with Staff #1 Julienna Barrera (Lead Staff) who allowed entry into the facility and also assisted with the visit.

The investigation consisted of the following: On 5/6/24, 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) face sheet, physician order, dental visit information, medical visit information and P&I Ledger. LPA also interviewed administrator, three staff (S2-S4) and four clients (C1-C4) and reviewed clients' mediation and P&I Ledger and tour of the facility/clients' closet. On 5/7/24, LPA also interviewed S1 and S5 via telephone. On 5/31/24, LPA also interviewed the facility regional director via telephone.
(See LIC 9099C for continuation)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024
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 5
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: 06/11/2024
NARRATIVE
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The investigation revealed of the following: Allegation#1 “Staff hit resident with an object which resulted in injuries. It is alleged that back in December 2023, S1 hit a client with a broom resulting in several injuries (black eye, gash over his eye, bruises from being grabbed leaving finger marks). LPA attempted to interview four clients, 2 of those 4 clients are non-verbal, 1 of the 4 clients denied the allegation, and the other client reported that they witnessed staff hit client with the broom however refused to provide additional information. LPA interviewed multiple staff members and they all denied the allegation. S1 indicated that one of the clients does not like him and will make false allegations against S1.

Allegation#2 “Staff used inappropriate form of punishment” It’s alleged that a staff member will “hose off” a client with cold water in the shower when the client engages in fecal smearing. This client is allegedly left in the shower for extended periods of time. LPA interviewed 2 clients that are verbal and they all denied the allegation. Clients interviewed indicated that they have not witnessed any staff hose down clients with cold water in the shower. All staff interviewed also denied the allegation. Staff members interviewed indicated that one of the clients likes to take long showers and staff will need to prompt the client to exit the shower, however staff is not forcing this client to shower with cold water nor are they forcing them to stay in the shower for long periods of time.

Allegation#3 “Staff falsified documents” It’s alleged that staff has been hiding special incident reports from the Department and have also falsified Pro-Act certifications in the home. All staff interviewed denied the allegation. Staff interviewed indicated that all of the Pro-Act Certificates were issued by a certified Pro-Act Instructor once staff have completed the required courses. These certificates are mailed directly to the facility Administrator via email and the House Manager will file the employee certificates in their personnel files. Facility Regional Director also confirmed this information.

Based on the record reviewed and interviews conducted with clients and staff, Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.



Exit interview conducted and a copy of the report and appeal right was provided to the Lead Staff Julienna Barrera.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024
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
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:
06/11/2024
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Julienna Barrera TIME COMPLETED:
09:05 PM
ALLEGATION(S):
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Staff financially abused resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wong conducted a subsequent visit to ascertain additional information regarding the above-mentioned allegation(s) and for the purpose of rendering the findings. LPA met with Staff #1 Julienna Barrera (Lead Staff) who allowed entry into the facility and assisted with the visit.

The investigation consisted of the following: On 5/6/24, 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) face sheet, physician order, dental visit information, medical visit information and P&I Ledger. LPA also interviewed administrator, three staff (S2-S4) and four clients (C1-C4) and reviewed clients' mediation and P&I Ledger and tour of the facility/clients' closet. On 5/7/24, LPA also interviewed S1 and S5 via telephone. On 5/31/24, LPA also interviewed the facility regional director via telephone.
(See LIC 9099C for continuation)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024
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 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: 06/11/2024
NARRATIVE
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The investigation revealed of the following: Allegation “Staff financially abused resident” It’s alleged S1 misuses clients’ funds, cuts clients’ hair and pays himself $30.00 after every haircut. LPA interviewed clients and it was reported that two staff members at the facility will cut clients hair and charge them $30.00 per haircut from their P&I monies. Staff members interviewed confirmed that haircuts are provided to clients and indicated that the facility house manager approved of this. Additionally, LPA conducted a review of clients P&I Ledger and observed handwritten receipts for the haircuts and some receipts were missing from two clients’ P&I Records. Interviews also revealed that the Regional Center was unaware that clients at the facility were receiving haircuts from facility staff. The facility Administrator also indicated that they were unaware that facility staff was charging the clients for haircuts.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.



Exit interview held with Lead Staff Julienna Barrera. A copy of the report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/18/2024
Section Cited
CCR
80026(h)(1)(B)
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80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents (h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following:(1) Records of clients' cash resources maintained as a drawing account, which shall include a current ledger accounting, with columns for income, disbursements and balance, for each client. Supporting receipts for purchases shall be filed in chronological order.
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The administrator will review the regulation to the staff and provide training for them and also write up a plan how to ensure to maintain accurate records of client's cash resources with receipts for client's P&I monies.
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B) The store receipt shall constitute the receipt for purchases made for the client from his/her account. The requirement was not met as two staff members at the facility will cut clients hair and charge them $30.00 per haircut from their P&I monies which posed a potential 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.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5