374604133-4-25-2025-08-AS-SJAB-DG8PJF-20250430112128

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604133
Report Date: 04/25/2025
Date Signed: 04/25/2025 03:49:26 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/02/2021 and conducted by Evaluator Marisela Garcia-Centeno

COMPLAINT CONTROL NUMBER: 08-AS-20210402133825

FACILITY NAME:	ELYON HOME CARE		FACILITY NUMBER:	374604133
ADMINISTRATOR:	VELASCO, JOFEL		FACILITY TYPE:	735
ADDRESS:	635 S HARBISON AVE		TELEPHONE:	(619) 227-7525
CITY:	NATIONAL CITY	STATE: CA	ZIP CODE:	91950
CAPACITY:	6	CENSUS: 5	DATE:	04/25/2025
		UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Caregiver, Alma Bayau		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Lack of care and supervision resulting in questionable death

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced complaint visit to deliver the findings of an investigation. LPA met with Caregiver, Alma Bayau. During the visit, LPA Garcia-Centeno discussed the report and shared the findings with Administrator, Jofel Velasco via telephone.

The Department investigated the complaint through observations, staff and witness interviews, and a detailed review of relevant records, including the client’s medical records and service care plans.

On April 2, 2021, Community Care Licensing (CCL) received a complaint alleging that neglect of Client 1 (C1) resulted in serious bodily injury. Additionally, on March 9, 2023, CCL received an incident report alleging that neglect and lack of care, and supervision contributed to C1’s questionable death on March 3, 2023. [Staff was provided the LIC 811 Confidential Name List to identify the client.]

(Continue at LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20210402133825

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ELYON HOME CARE	FACILITY NUMBER: 374604133
	VISIT DATE: 04/25/2025

NARRATIVE

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(Continue from LIC9099)

Based on record reviews and interviews, it was determined that on March 30, 2021, C1 experienced an unwitnessed fall, resulting in a rib fracture. Multiple interviews with staff and outside sources, as well as a thorough review of medical records, found no corroborating evidence to suggest that the injury resulted from staff neglect. An interview with the reporting party confirmed the incident was reported as part of mandated reporting requirements, and they did not suspect staff neglect as the cause.

Additionally, on February 21, 2023, C1 sustained a serious head injury from a witnessed fall. Staff immediately sought emergency medical assistance, and C1 was transported to the hospital by ambulance.

A review of C1’s medical records and service care plans revealed diagnoses of profound intellectual disability, impulse control disorder, and other mental health conditions commonly associated with individuals with intellectual disabilities. C1 was non-verbal, wheelchair-dependent, and required assistance with all activities of daily living, including dressing, bathing, incontinence care, grooming, and oral hygiene. Medical records also showed a history of falls and self-injurious behaviors.

Staff interviews consistently confirmed that C1 received one-on-one care and 24/7 supervision, including at night, due to a high fall risk. Staff stated that C1 typically required incontinence care between 1:00 and 2:00 a.m. On February 21, 2023, around 2:00 a.m., while being assisted with incontinence care, C1 abruptly pushed their wheelchair, causing it to tip over and resulting in a fall. A second staff member immediately responded to assist. Interviews consistently noted that C1’s quick and impulsive behavior necessitated one-on-one supervision. Outside sources also indicated that, despite C1’s history of falls and self-harm, staff were meeting C1’s care and supervision needs appropriately.

A review of C1’s death certificate listed the cause of death as accidental blunt head trauma, with complications from a chronic subdural hematoma and ventricular hemorrhage. Facility staff acted promptly and appropriately following the fall. A detailed review of incident reports submitted to CCL revealed no violations of Title 22 regulations. Facility staff followed protocol and adhered to all reporting requirements.

(Continue at LIC9099C)

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20210402133825

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ELYON HOME CARE	FACILITY NUMBER: 374604133
	VISIT DATE: 04/25/2025

NARRATIVE

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(Continue from LIC9099C)

Based on the evidence gathered, the preponderance of evidence was not established to support the allegation that staff neglect or lack of supervision led to C1’s death. Therefore, the allegation is unsubstantiated.

An exit interview was conducted with Caregiver, Bayau and Administrator Velasco via the telephone. Copies of this report, the LIC 811 Confidential Name List, and the Licensee Appeal Rights (LIC 9058 03/22) were provided at the conclusion of the visit to Bayau.

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025

LIC9099 (FAS) - (06/04)

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