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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415650019
Report Date: 11/17/2023
Date Signed: 11/17/2023 03:39:00 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/14/2023 and conducted by Evaluator Mariah Hawkins
PUBLIC
COMPLAINT CONTROL NUMBER: 14-CR-20230614083655
FACILITY NAME:ELYSIANFACILITY NUMBER:
415650019
ADMINISTRATOR:AIMEE SALAZAR-NUNEZFACILITY TYPE:
733
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:12CENSUS: 4DATE:
11/17/2023
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Senior Human Services Care Counselor Julia BarbozaTIME COMPLETED:
02:55 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff gave minor abortion pills without consent
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/17/23, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility to deliver complaint investigation findings. LPA met with Senior Human Services Care Counselor Julia Barboza and informed of the purpose of the visit.

Based on confidential interviews, observations, and record review, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated. It was found that documentation and statement from administering staff reflect a prescribed contraceptive medication was administered to the appropriate resident and not to the involved resident. However, a statement could not be obtained from the involved resident due to hospitalization and later runaway behavior resulting in the resident being unavailable for interview.
An exit interview was conducted, appeal rights provided, and a copy of this report was left with Senior Human Services Care Counselor Julia Barboza, whose signature on this report confirms receipt.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lidia Tinoco
LICENSING EVALUATOR NAME: Mariah Hawkins
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023
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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