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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803726
Report Date: 03/27/2023
Date Signed: 03/27/2023 04:02:18 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/22/2023 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20230322142833
FACILITY NAME:ELWYN CALIFORNIA - BARNESFACILITY NUMBER:
496803726
ADMINISTRATOR:WEBSTER, SUSANFACILITY TYPE:
737
ADDRESS:4151 BARNES RDTELEPHONE:
(707) 791-3937
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:4CENSUS: DATE:
03/27/2023
UNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:Judy Colombo-Psych TechTIME COMPLETED:
03:41 PM
ALLEGATION(S):
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Facility is not operating in a sanitary manner and/or in good repair; Clients are not able to use restroom toilets in a sanitary manner

Facility is not submitting required reports/incidents


INVESTIGATION FINDINGS:
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Licensing Program Analyst(LPA) Alviso conducted a complaint visit, 3/27/23 at approximately 9:00am, and met with staff Judy Colombo. LPA asked that the Adminstrator Susan Webster to be notified that the LPA had arrived at the facility to conduct a complaint visit. Administrator Susan arrived shorthly after the LPA's arrival. The LPA toured the facility with the Administrator; The LPA checked both facility bathrooms, and observed the toilets were flushing and working properly during today's inspection. LPA conducted interviews, reveiwed facility records, and reviewed obtained information during the investigation. The investigation revealed that the facility had an incident that occurred on 3/13/23 at approximately 7pm, that one(1) bathroom out of the two(2) had a clogged toilet. Staff stated they contacted Brilliant Corners Property Management for a plumber. On 3/14, approximately 10:55am, Roto Rooter came out and identified to staff that it was a septic tank issue and the tank was full and needed to be emptied. Per Staff, Roto Rooter stated once the tank was emptied a cap had to put on so the tank wouldn't become filled with water again, due to the rain/storms. BDK Septic came out and drained the septic tank. Roto Roter came back to put the cap on but the septic tank was full again. Facility was told to not use the toilets due to the full septic tank. Facility staff let the Brilliant Corners property management company know about the septic tank problem. The facility staff on 3/14 started using plastic bags in the toilets for clients to use to urinate and/or for bowel movements, this was happening at least to 3/15 per interviews, if not longer.
Continued on LIC9099C..
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
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 6
Control Number 21-AS-20230322142833
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ELWYN CALIFORNIA - BARNES
FACILITY NUMBER: 496803726
VISIT DATE: 03/27/2023
NARRATIVE
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 Staff stated they would take the plastic bags out to the facility's trash cans outside. S1 stated they didn't think to go to a hotel in order to have working bathrooms for residents in care until the facility bathrooms were working properly. The plastic bags of clients waste was put into te regular trash cans. This deficiency will be cited, Buildings and Grounds 80087(a), Personal Rights 80072(a)(2), see LIC9099D.
There was a porta potty brought onto the facility property on 3/15 for staff use; Per interviews, clients continued using plastic bags in the facility toilets and these bags would be taken out by staff to the trash once used. Per S1, facility residents are using the toilets in the facility and have been since 3/15/23. Per staff, S1, stated to the LPA that clients received showers unless refusing one during the incident. LPA reviewed facility records and the records weren't clear on if some of the clients received showering/bathing during the incident. Staff stated the clients were bathed if they wanted to and not if they refused.
On 3/17 BDK was out to the facility and drained the septic tank and also capped it. BDK came out 3/22 due to the rains and emptied the septic tank. again. Per S1, the water is fine and can be consumed this has never been a problem in the facility. We do wash laundry in the facility but we use the Laundromat due to lots of sediment buildup tat happens with the washing machine due to the water. LPA observed a load of laundry being washed and dried in the facility.
S1 stated to the LPA that they had not reported the incident to licensing office when they should have but did send a report on 3/22/23. The LPA discussed reporting requirements, per regulations with the staff; The incident started the evening of 3/13/23, and was reported to the licensing office on 3/22/23, this is not within regulation time frame. This deficiency will be cited, 80061(b)(1)(E) Reporting Requirements, see LIC9099D.

The Licensing Office will contact you/Elwyn California regarding having a Regional Office non-compliance conference meeting with our Managers. I will be in touch with you/Administrator to set up a day and time.

Based upon LPA investigation, observation, statements taken, and records reviewed, the preponderance of evidence standard has been met. Therefore, the above captioned allegations are SUBSTANTIATED. The following deficiencies were observed and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal rights given.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 21-AS-20230322142833
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ELWYN CALIFORNIA - BARNES
FACILITY NUMBER: 496803726
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/28/2023
Section Cited
CCR
80087(a)
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80087(a)-Buildings & Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement wasn't met as evidenced by: LPA's observations, record rebiews, and interviews with staff and other parties.
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Facility to submit plan of correction in ensuring compliance with regulations and a plan in how the facility will address emergencies in the future, including septic tank issues, where bathroom
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The facility staff on 3/14 started using plastic bags in the toilets for clients to use to urinate and/or for bowel movements, this was happening through to at least 3/15 per interviews, if not longer.The plastic bags of clients waste was put into the regular trash cans outside. This is an immediate risk and/or personal rights risks to all clients in care.
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facilities/toiletsare not working properly, ensuring the plan is within regulations. Submit the POC by 3/28/23.
Type B
03/28/2023
Section Cited
CCR
80072(a)(2)
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80072(a)(2)Personal rights(a) Each client shall have personal rights which include, but are not limited to, the following (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement wasn't met as evidenced by: LPA's observations, record rebiews, and interviews with staff and other parties.
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Facility to submit plan on how the facility will ensure clients rights are not violated at any time and that the facility will ensure all buildings and grounds requirements are in compliance at all times,
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The facility staff on 3/14 started using plastic bags in the toilets for clients to use to urinate and/or for bowel movements, this was happening through to at least 3/15 per interviews, if not longer.The plastic bags of clients waste was put into the regular trash cans outside. This is an immediate risk and/or personal rights risks to all clients in care.
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 that clients needs are met as required, and services are provided in a sanitary safe manner at all times. Facility to submit plan of correction by 3/28/23.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 21-AS-20230322142833
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ELWYN CALIFORNIA - BARNES
FACILITY NUMBER: 496803726
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/31/2023
Section Cited
CCR
80061(b)(1)(e)
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Reporting Requirements(b)(1) E) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.(1)Events reported shall include the following: (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
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Facility to submit a plan of correction in regards to reporting as required to Licensing Department and all Agencies, per regulations.Submit how the facility will ensure reporting is done. Submit POC by due date of 3/31/23.
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This requirement was not met as evidenced by: LPA's investigation, review of records, interviews with staff & other parties. The facility didn't submit an incident report as required by regulation, incident that started on 3/13. Staff states report sent 3/22/23.This is an immediate health and safety risk and/or a personal rights 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.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/22/2023 and conducted by Evaluator Dina Alviso
COMPLAINT CONTROL NUMBER: 21-AS-20230322142833

FACILITY NAME:ELWYN CALIFORNIA - BARNESFACILITY NUMBER:
496803726
ADMINISTRATOR:WEBSTER, SUSANFACILITY TYPE:
737
ADDRESS:4151 BARNES RDTELEPHONE:
(707) 791-3937
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:4CENSUS: DATE:
03/27/2023
UNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:Judy Colombo-Psych TechTIME COMPLETED:
03:41 PM
ALLEGATION(S):
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Clients are not able to be bathed/showered as needed
INVESTIGATION FINDINGS:
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Licensing Program Analyst(LPA) Alviso conducted a complaint visit, 3/27/23 at approximately 9:00am, and met with staff Judy Colombo. LPA asked that the Adminstrator Susan Webster to be notified that the LPA had arrived at the facility to conduct a complaint visit. Administrator Susan arrived shorthly after the LPA's arrival. The LPA toured the facility with the Administrator; The LPA checked both facility bathrooms, and observed the toilets were flushing and working properly during today's inspection. LPA conducted interviews, reveiwed facility records, and reviewed obtained information during the investigation. The investigation revealed there was differing information regarding te allegation. The investigation did not find a preponderance of information to substantiate that this violation occurred. Per S1, facility residents are using the toilets in the facility and have been since 3/15/23. Per staff, S1, stated to the LPA
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 21-AS-20230322142833
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ELWYN CALIFORNIA - BARNES
FACILITY NUMBER: 496803726
VISIT DATE: 03/27/2023
NARRATIVE
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that clients received showers unless refusing one during the incident. LPA reviewed facility records and the records weren't clear on if some of the clients received showering/bathing during the incident. Staff stated the clients were bathed if they wanted to and not if they refused. On 3/17 BDK was out to the facility and drained the septic tank and also capped it. BDK came out 3/22 due to the rains and emptied the septic tank. again. Per S1, the water is fine and can be consumed this has never been a problem in the facility. We do wash laundry in the facility but we use the Laundromat due to lots of sediment buildup tat happens with the washing machine due to the water. LPA observed a load of laundry being washed and dried in the facility.

Although the allegation may have happened based upon statements and record review, there is not a preponderance of evidence to prove the allegations are, or are not, true. Therefore, the allegations are UNSUBSTANTIATED.

There are no deficiencies cited. Exit interview conducted with the Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6