197604283-5-26-2022-31-AS-EMIR-CGGQB8-20220719120107

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197604283
Report Date: 05/26/2022
Date Signed: 05/26/2022 03:42:52 PM

Unsubstantiated

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
04/02/2021 and conducted by Evaluator Michael Cava

COMPLAINT CONTROL NUMBER: 31-AS-20210402101601

FACILITY NAME:	ELDER CREEK VILLA II		FACILITY NUMBER:	197604283
ADMINISTRATOR:	RAPISURA, ALFREDO		FACILITY TYPE:	740
ADDRESS:	21113 ELDER CREEK DR		TELEPHONE:	(661) 713-0313
CITY:	SAUGUS	STATE: CA	ZIP CODE:	91350
CAPACITY:	6	CENSUS: 6	DATE:	05/26/2022
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Tems Bargamento		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Resident sustained injuries while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michael Cava conducted a subsequent complaint visit to the facility to issue the findings regarding the above allegation. It was reported that Resident (R1) sustained unexplained bruises to the chest and arm. R1’s relative did not see the bruises during the previous day’s visit. No fractures were found when R1 was brought to the hospital for X-rays, but when R1 was treated by hospital staff, R1 would become very defensive, holding up her fists. An allegation of abuse was reported at that point because there were some concerns of potential abuse. The initial ten day visit was conducted by LPA Naira Margaryan. Complaint was then referred to Investigations Branch, and assigned to Investigator Dennis Douglas for full investigation.

During the course of IB’s investigation, interviews and record review were conducted. Per interviews with facility staff, the allegation of abuse is denied. There were no witnesses identified to corroborate the allegation. Interview with R1’s relative reveal that they are happy with the care provided to R1 and never had any concerns regarding the

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022

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 31-AS-20210402101601

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 II	FACILITY NUMBER: 197604283
	VISIT DATE: 05/26/2022

NARRATIVE

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level of care provide by facility staff. R1’s relative did not have any concerns of abuse, and believes the bruises sustained was a result from a fall. IB also interviewed another client who stated they did not witness or observe either abuse by facility staff or any falls.

Per medical records, contusion sustained to the chest area was likely from complications of a fall. It was indicated on R1’s medical records that R1 had a history of falling due to an impaired gait.

Based on the information obtained, there was insufficient evidence to confirm the allegation of resident sustaining injuries while in care due to potential abuse. Therefore, the allegation is deemed Unsubstantiated at this time.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022

LIC9099 (FAS) - (06/04)

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