435202112-5-12-2026-26-AS-RMAO-DURJXL-20260605072632

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202112
Report Date: 05/12/2026
Date Signed: 05/12/2026 04:53:42 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/10/2026 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20260210115807

FACILITY NAME:	ELWYN NC - WELLINGTON PARK		FACILITY NUMBER:	435202112
ADMINISTRATOR:	FAY CACDAC		FACILITY TYPE:	735
ADDRESS:	4865 WELLINGTON PARK DR		TELEPHONE:	(408) 281-1116
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95136
CAPACITY:	4	CENSUS: 4	DATE:	05/12/2026
		UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Nelia Hao Guan		TIME COMPLETED:	09:41 AM

ALLEGATION(S):

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Staff do not properly supervise resident, resulting in resident trespassing
onto neighbor's property

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA ) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with House Manager (HM) Nelia Hao Guan.

On 02/102026, the Department received a complaint with the allegation that staff do not properly supervise resident, resulting in resident trespassing onto neighbor's property.

On 02/20/2026, the Department conducted an initial investigation visit.

LPA interviewed ADM and 3 staff (S1 - S3). LPA toured the resident rooms with ADM. LPA checked the facility exit doors.

LPA requested resident R1's physician report, appraisal needs and service plan, LIC500, incident reports.
Continue on LIC9099-C. Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026

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 26-AS-20260210115807

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ELWYN NC - WELLINGTON PARK	FACILITY NUMBER: 435202112
	VISIT DATE: 05/12/2026

NARRATIVE

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The allegation is that staff did not supervise resident R1, resulting in R1 trespassing onto neighbor's property.

On 02/20/2026, LPA interviewed Administrator (ADM) Fay Cacdac. ADM stated on 02/07/2026, Saturday, around 5:10PM, after resident R1 had snack in dining room and was walking back to his/her bedroom. Suddenly R1 rushed to the main door and exited. ADM stated two staff (S1, S2) followed R1 immediately to redirect him/her to get on facility VAN and offered R1 an outing to get something he/she likes. ADM stated R1 got on the facility VAN but then suddenly got off the facility VAN and ran to neighbor house. ADM stated two staff followed R1 immediately to the neighbor house. The two staff offered R1 cookies and redirected R1 returned to the facility. ADM stated before and on 02/07/2026, R1 had 2:1 caregivers Monday to Friday from 3:00PM to 7:00PM, and Saturday, Sunday from 9:00AM to 5:00PM.

ADM stated after the incident, R1 has 2:1 caregivers from 11:00AM to 7:00PM on Saturday, from 10:30AM to 6:30PM on Sunday., and Monday to Friday from 3:00PM to 7:00PM. ADM stated except R1's 2:1 caregivers, R1 also has 1:1 caregiver for 8 hours from Monday to Friday and 1:1 caregiver for 14 hours on Saturday and Sunday. ADM stated the facility has exit door alarms setup for 24 X 7.

LPA interviewed 3 staff (S3, S4, S5). 3 Out of 3 staff stated on 02/07/2026, R1 exited the facility and went to the neighbor house. 3 Out of 3 staff confirmed 2 facility staff followed R1 immediately to the neighbor house and redirected R1 back to the facility. 3 Out of 3 staff stated R1 does not behave aggressively and R1 does not hit or hurt others.

Based on review of R1's progress notes, on 02/07/2026, R1 exited the facility and went to the neighbor house. Two staff followed R1 immediately to the neighbor house and redirected R1 back to the facility.

Based on the review of incident reported dated 02/07/2026, on 02/10/2026, R1 went to neighbor house and two staff followed him/her immediately. The two staff redirected R1 back to the facility. No one hurt or obtained injuries. R1 rang the neighbor doorbell but did not enter the neighbor house.

Based on the review of the email log, the facility nurse and Board Certified Behavior Analyst (BCBA) reviewed and discussed on R1's medication regarding R1's behavior.

Continue on LIC9099-C. Page 2 of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20260210115807

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ELWYN NC - WELLINGTON PARK	FACILITY NUMBER: 435202112
	VISIT DATE: 05/12/2026

NARRATIVE

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Based on the interview and records reviewed, the facility provided 2:1 caregivers to supervise R1 before the incident on 02/07/2026 and after the incident the facility provides 8 hours of 2:1 care and 14 hours of 1:1 care to R1 on Saturday and Sunday, and 4 hours of 2:1 care and 8 hours of 1:1 care to R1 on Monday to Friday, and R1 has day program form Monday to Friday in the morning and in the afternoon.

For the incident on 02/07/2026, staff found R1 exited the facility and two staff followed R1 immediately. R1 rang the neighbor doorbell but did not enter the neighbor's house and two staff redirected R1 back to the facility.

The department has investigated the above allegation. Based on records reviewed, and interviews conducted, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

No citations noted at today’s compliant investigation visit. Exit interview conducted with HM. A copy of this report was provided to HM.

Page 3 of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 3