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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603466
Report Date: 05/17/2022
Date Signed: 05/17/2022 01:08:45 PM


Document Has Been Signed on 05/17/2022 01:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 VILLAFACILITY NUMBER:
197603466
ADMINISTRATOR:RAPISURA, ALFREDOFACILITY TYPE:
740
ADDRESS:21121 ELDER CREEK DRIVETELEPHONE:
(661) 263-6162
CITY:SAUGUSSTATE: CAZIP CODE:
91350
CAPACITY:6CENSUS: 6DATE:
05/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:32 AM
MET WITH:Jesse ManuelTIME COMPLETED:
12:46 PM
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Licensing Program Analyst (LPA) Abeye Duguma met with Assistant Administrator Jesse Manuel for a One (1) Year Required - Infection Control visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at 9:30am and the following was noted:
There is one entrance being utilized at the facility, there are required posters posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, infrared thermometer, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing masks upon entrance and during the visit. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated outdoor visitors' area located in backyard. The facility has sufficient stock of PPE in a storage cabinet located in the kitchen. The facility has a total of six (06) bedrooms for residents, one (01) for staff and two (02) bathrooms for both residents and staff. The facility is fire cleared for six (06) non-ambulatory and a hospice waiver for two (02). The facility is currently occupying six (06) non-ambulatory residents of which one (01) is on hospice care. The facility has outdoor furniture with a covered shaded area (umbrella) for residents. The facility does not have a swimming pool/body of water. The garage is being used for storage and laundry. Laundry detergents, cleaning agents and other toxins are stored in the locked garage. Kitchen area was sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents. The living and dining room are neat and clean. The facility maintains a comfortable temperature at 75°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational.
(continued on LIC 809-C)
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/17/2022
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 Fire extinguisher is located in the kitchen, observed to be full and last purchased 12/31/2021. The facility is equipped with a fire sprinkler system. The residents' rooms are adequately furnished with appropriate lighting system. Hallways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 113.3°F. Towels and washcloths are not shared. There was enough clean linen available in the cabinets. LPA observed medication and first aid kit to be locked and inaccessible to residents.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
LIC809 (FAS) - (06/04)
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