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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603466
Report Date: 05/13/2021
Date Signed: 07/14/2021 12:34:41 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/06/2021 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20210506145942
FACILITY NAME:ELDER CREEK VILLAFACILITY NUMBER:
197603466
ADMINISTRATOR:RAPISURA, ALFREDOFACILITY TYPE:
740
ADDRESS:21121 ELDER CREEK DRIVETELEPHONE:
(661) 263-6162
CITY:SAUGUSSTATE: CAZIP CODE:
91350
CAPACITY:6CENSUS: 5DATE:
05/13/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jessie ManuelTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff storing expired food.
Facility not allowing visitors.
Chemicals are accessible to resident's.
Facility not following proper infection control process to prevent the spread of COVID-19
INVESTIGATION FINDINGS:
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This is an amended report. It takes the place of the report issued on 5/13/2021. Findings remain the same.
Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced initial complaint visit to investigate the allegations above. Upon entry to the facility, LPA met with facility staff and explained the reason for this visit.
LPA spoke with the administrator Alfredo Rapisura by telephone at approximately 10:05 am and explained the reason for this visit.
Staff storing expired food
It is alleged that on 4/28/21 facility was observed to have expired food in the refrigerator such as yogurt and peanut butter. At approximately 10:15am, LPA conducted a physical plant walk through of the facility which included the kitchen. LPA checked the food supply. At approximately 10:25 am, LPA conducted an interview with staff who shared that they did have food that was expired in the refrigerator that was thrown away when brought to their attention. Based upon the information obtained through interviews this allegation is deemed Substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021
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 4
Control Number 31-AS-20210506145942
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ELDER CREEK VILLA
FACILITY NUMBER: 197603466
VISIT DATE: 05/13/2021
NARRATIVE
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Facility not allowing visitors
It is alleged that the facility is not allowing visitors at this time. Upon entry to the facility at 10am, LPA noticed a posting on the door that stated that facility was restricting visiting to only essential healthcare personnel. At 10:05 am, LPA spoke with the administrator regarding the posting and he stated that they do allow visits to be scheduled. LPA explained that what is posted on the entry door to the facility contradicts the visiting policy. Based on information obtained through observation this allegation is deemed Substantiated. Administrator did state that the posting would be removed from the door.


Chemicals are accessible to resident's.
It is alleged that on 4/28/21 cleaning solution was accessible to residents in the bathroom. During the physical plant walk through at 10:15am, LPA spoke with facility staff who confirmed that this did happen and that the cleaning solution was locked away immediately. Based on information obtained through interviews this allegation is deemed Substantiated.

Facility not following proper infection control process to prevent the spread of COVID-19
It is alleged that facility does not properly screen visitors prior to entry to the facility or take any temperatures prior to visitors entering the facility. Upon entry to the facility at 10:am, LPA was not screened or did anyone take LPA's temperature. LPA was also informed the facility did not have any more personal protection equipment (PPE). Based upon the information obtained through observation and interviews this allegation is deemed Substantiated.
All deficiencies cited on LIC 9099 D. Appeal Rights explained. Exit Interview conducted. Copy of report emailed for signature.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20210506145942
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELDER CREEK VILLA
FACILITY NUMBER: 197603466
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2021
Section Cited
CCR
87468.1(a)(2)
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Personal Rights-To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement was not met as evidenced by:
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Administrator shall have an in-service training with staff on the importance of screening all visitors and taking temperatures of everyone entering the facility. Copy of the in-service sign in sheet will be submitted to clear the citation.
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Based on observation the facility fails to do a properly screen visitors or take temperatures of visitors upon entry to the facility which can pose a potential health and safety risk to residents in the facility.
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Type B
05/17/2021
Section Cited
CCR
87468.1(a)(11)
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Personal Rights- To have their visitors permitted to visit the facility privately during reasonable hours.
This requirment was not met as evidenced by:
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Administrator shall take the signage down regarding visiting to the facility and update it to correctly show the current visiting policy. Administrator shall contact residents responsible persons and inform them of the updated visiting policy. Self certification will be sent to LPA once this is done to clear this citation.
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Based on observation the facility has a sign upon entry that states all visits are restricted unless you are an essential healthcare worker.
This poses a personal rights issue to residents in care by not allowing them to have visitors.
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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: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20210506145942
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELDER CREEK VILLA
FACILITY NUMBER: 197603466
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/13/2021
Section Cited
CCR
87555
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General Food Service Requirements-All food shall be selected, stored, prepared and served in a safe and healthful manner.
This requirement was not met as evidenced by:
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Corrected before visit. Expired food was thrown out.
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Based on information obtained through interviews on 4/28/21 facility had expired food stored in the refrigerator which posed a potential health and safety risk to the residents in care.
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Type B
05/13/2021
Section Cited
CCR
87705(f)(2)
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Care of persons with Dementia- The following should be stored inaccessible to residents that have dementia cleaning supplies and disinfectants.
This requirement was not met as evidenced by:
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Corrected before visit. The cleaning solution was immediately locked away.
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Based on interviews conducted on 4/28/21 cleaning solution was found accessible to residents in care which posed as a health and safety risk to residents 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: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4