435202196-5-24-2023-26-AS-KHOS-CSHJP8-20230605071307

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202196
Report Date: 05/24/2023
Date Signed: 05/24/2023 11:54:17 AM

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
01/10/2023 and conducted by Evaluator Christine Dolores

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20230110093638

FACILITY NAME:	ELWYN NC - LA ALAMEDA		FACILITY NUMBER:	435202196
ADMINISTRATOR:	CANOSA, JOCELYN		FACILITY TYPE:	734
ADDRESS:	15470 LA ALAMEDA DR		TELEPHONE:	(408) 779-5353
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY:	5	CENSUS: 2	DATE:	05/24/2023
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	NOBUHLE MANYIKA		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff handled client in a rough manner
Staff did not safeguard client’s personal belongings

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the findings for the above allegations. LPA met with Administrator Nobuhle Manyika and Designated Administrator, Cynthia Octabiano.

On 01/10/2023, the Department received a complaint regarding the above allegations. It’s alleged a resident was handled in a rough manner by an unknown staff member. It’s also been alleged staff did not safeguard a resident’s personal belongings from the observation of missing items. On 01/12/2023, the initial complaint investigation was conducted by LPA Dolores.

The following documents were obtained to include facility client roster, staff schedule from November 2022 – December 2022, and R1 – R4’s safeguard of personal property and valuables form.

On 01/12/2023, two staff members (S1 – S2) were interviewed. S1 – S2 denied observations of clients being handled in a rough manner when assisting residents with their activity of daily living (ADLs). SEE LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

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 26-AS-20230110093638

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 - LA ALAMEDA	FACILITY NUMBER: 435202196
	VISIT DATE: 05/24/2023

NARRATIVE

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On 04/28/2023, 2 witnesses (W1 – W2) were interviewed. W1 – W2 stated residents at the facility are treated “fine”. W1 – W2 stated they did not observe any staff were providing care in a rough manner during their visits to the facility.

Based on interview with the complainant, they described the suspected abuser by race, but the name and specific description was unknown. Based on observation, there was no indication the residents were being provided improper care by no observation of obvious bruising of the skin or indications of pain. The review of the Department’s records did not show any reports that may be relating to a resident sustaining an injury or being provided improper care at the facility.

On 04/28/2023, two witnesses (W1 – W2) were interviewed. Based on interview with W1, it’s alleged R1 is missing multiple clothing items. Based on record review, resident (R1) only had 5 items listed on their safeguard of personal property and valuables form. The items that were alleged missing were not part of the items that were safeguarded. The Department was also not provided specific descriptions of the items that are alleged missing but rather vague descriptions. Based on interview with W2, there are no concerns or issues regarding missing items of R2’s.

Based on record review, interview, and observation the Department has investigated the above allegations to be unsubstantiated. An unsubstantiated finding means although the allegation may have happened and/or is valid there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator Nobuhle Manyika and Designated Administrator, Cynthia Octabiano and a copy of the report was provided.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

LIC9099 (FAS) - (06/04)

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