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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602217
Report Date: 12/14/2023
Date Signed: 12/14/2023 03:14:33 PM

Substantiated


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
12/13/2023 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20231213084207
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:
12/14/2023
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Martin Sy TIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility staff are not adequately trained.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Wong conducted an initial 10 days complaint visit and ascertain information pertaining to the above-mentioned allegation(s) and to establish the validity of the complaint. LPA met with the House Manger Estela Barrrera and explained the reason of the visit. Later on, LPA met with the Administrator Martin Sy and assisted with the visit.

The investigation consisted of the following: On today's date, LPA interviewed four (4) clients, house manger and administrator. LPA also reviewed six (6) staff files about their training hours.

The investigation revealed of the following : Allegation "Facility staff are not adequately trained." LPA received the Corrective Action Plan (CAP) from San Gabriel Pomona Regional Center. It's indicated that the facility staff was lacking of specialized skill training as the facility is a specialized behavioral home.

(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: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
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 3
Control Number 28-AS-20231213084207
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: 12/14/2023
NARRATIVE
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 LPA reviewed six (6) staff files during the investigation and three (3) out of six (6) staff files do not have the required specialized skill training in file since hired. As the facility is a specialized behavioral home, the facility staff required to have the specialized skill to perform their job duties and provide care and supervision to clients.

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

Exit interview held with Administrator Martin Sy. 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: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20231213084207
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: 12/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/28/2023
Section Cited
CCR
85065(f)
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85065 Pesonnel Requirements (f) The licensee shall ensure that all direct services to clients requiring specialized skills are performed by personnel who are licensed or certified to perform the service.
The requirement was not met as evidenced by :
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Administrator to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Administrator to submit a faxed or mailed copy of POC by due date.
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Documents reviewed, LPA reviewed 6 staff files and observed 3 out of 6 staff files do not have the specialized required skill training in file since hired 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: 12/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3