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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602891
Report Date: 07/16/2024
Date Signed: 07/16/2024 03:25:35 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/09/2024 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240709092153
FACILITY NAME:ELWYN CALIFORNIA - EL MONTEFACILITY NUMBER:
198602891
ADMINISTRATOR:ADALID SOLANO GUTIERREZFACILITY TYPE:
735
ADDRESS:12052 CONFERENCE STTELEPHONE:
(626) 672-0248
CITY:EL MONTESTATE: CAZIP CODE:
91732
CAPACITY:4CENSUS: 4DATE:
07/16/2024
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Administrator Adalino Solano TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility staff did not prevent physical altercation between residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Staff S1 and explained the reason for the visit.Shortly thereafter the Administrator arrived.
The purpose of the visit is to investigate the above allegation.
At today's visit the following occurred:
Resident and Staff Roster and Special Incident Report (SIR) were submitted..
Interview was conducted with the Administrator at 1:45 PM.
Interview was conducted with Staff S1-S3 from 12:50 PM to 1:40 PM.
Attempts were unsuccessful to interview Client's C2 and C3 who are non verbal and unable to respond to questioning. Interview with Client C4 was conducted at 2:30 PM.
Interview was conducted with Staff S4 telephonically at 2:45 PM.
LPA reviewed Client C1's file and facility submitted Individual Program Plan (IPP), Emergency Face Sheet and Physician's Report.
LPA reviewed Special Incident Report (SIR), SOC 341 and Client Notes.

Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
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 28-AS-20240709092153
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ELWYN CALIFORNIA - EL MONTE
FACILITY NUMBER: 198602891
VISIT DATE: 07/16/2024
NARRATIVE
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In regards to the allegation, Facility staff did not prevent physical altercation between residents, based on interviews conducted and information gathered it was revealed that on 07/07/2024 facility Staff S4 submitted an SOC341 which stated that an incident occurred on 07/07/2024 at 10:30 AM in which Client C1 was sitting on the couch waiting for a sandwich being made by Staff S2 who is 1 on 1 staff for Client C1 and was in the kitchen.
Stated that Client C1 stood up and pulled Client C2 by the hair pulling a chunk of hair out from her scalp.
Interviews with the Administrator and Staff S4 confirmed that Client C1 was on the couch and Staff S2 was making her a sandwich and was in the kitchen.
Regional Center also confirmed that the information they have obtained is that the 1 on 1 for C1 was in the kitchen and Client C1 was on the couch in the living room.
Interview with Client C1 who stated she pulled Client C2's hair and Staff S2 was in the kitchen and ran over
to intervene.
Client Notes were written by Staff S4 on 07/07/2024 and stated that Staff S2 stated that Client C1 stood up and pulled Client C2 by the hair pulling a chunk of hair out from her scalp and the 1 on 1 Staff S2 was in the kitchen making a sandwich.
Review of IPP listed under Physical Aggression it states that Client C1 will decrease the frequency of physical aggression from 15.42 occurrences per month to 7 occurrences.

Based on LPA's observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22) cited on the attached 9099 D.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20240709092153
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ELWYN CALIFORNIA - EL MONTE
FACILITY NUMBER: 198602891
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/19/2024
Section Cited
CCR
80072(a)(1)
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Personal Rights
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:

(1) To be accorded dignity in his/her personal relationships with staff and other persons.
This requirement is not met as evidenced by:







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Facility to submit by the POC due date a behavioral plan addressing the procedure regarding 1 on 1 supervision.
Plan was submitted to Regional Center and submitted at today's visit.

Deficiency cleared.
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Based on interviews and file review facility failed to prevent clients from an altercation which posed a potential Health, Safety or Personal Rights risk to residents 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: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3