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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197604283
Report Date: 07/01/2022
Date Signed: 07/01/2022 02:26:46 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
12/03/2020 and conducted by Evaluator Michael Cava
COMPLAINT CONTROL NUMBER: 31-AS-20201203160048
FACILITY NAME:ELDER CREEK VILLA IIFACILITY NUMBER:
197604283
ADMINISTRATOR:RAPISURA, ALFREDOFACILITY TYPE:
740
ADDRESS:21113 ELDER CREEK DRTELEPHONE:
(661) 713-0313
CITY:SAUGUSSTATE: CAZIP CODE:
91350
CAPACITY:6CENSUS: 6DATE:
07/01/2022
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Max HamiltonTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Residents have access to sharp objects
Residents have access to hazardous materials
Medications are not adequately stored
Pool is not secured
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Cava conducted a subsequent complaint visit to the facility to conclude the investigation regarding the above allegations. The 10 day visit was conducted by LPA Arambulo on 12/03/20. During the course of the investigation, LPA met with staff, Max Hamilton and conducted a physical plant inspection.

Residents have access to sharp objects/Residents have access to hazardous materials:
In regards to the allegation, Licensing received a report from a credible source, revealing that on or around 11/24/20, knives under the kitchen sink were in an open container, left unlocked and unattended. It was also observed that laundry detergent was left on the kitchen cabinet, left unlocked and unattended. Although LPA Cava conducted an inspection of the physical plant on this date, and did not observe these items accessible to the residents in care, based on the observation of the credible source, the above allegations are Substantiated. Citation issued on the 9099D.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022
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-20201203160048
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: 07/01/2022
NARRATIVE
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Medications are not adequately stored:
In regards to the allegation, Licensing received a report from a credible source, revealing that on or around 11/24/20, medications were left out on the shelf, accessible and unattended. Although LPA Cava conducted an inspection of the physical plant on this date, and did not observe medications out and accessible to the residents in care, based on the observation of the credible source, the above allegation is Substantiated. Citation issued on the 9099D.

Pool is not secured:
In regards to the allegation, Licensing received a report from a credible source, revealing that on or around 11/24/20, the backyard pool was not locked properly, leaving it accessible to residents. Although LPA Cava conducted an inspection of the physical plant on this date, and observed the gate to the pool being locked and inaccessible, along with a five foot fence around the parameters of the pool, based on the observation of the credible source, the above allegation is Substantiated. Citation issued on the 9099D.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20201203160048
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/01/2022
Section Cited
CCR
87309(a)
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Storage Space: Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement has not been met as evidenced by the Licensing agency receiving a report from a credible source
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During the visit 7/1/22, LPA conducted an inspection of the physical plant and did not observe knives, cleaning solutions or any other items which could pose a danger accessible to the residents in care. No further corrections needed at this time.
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reporting that knives and laundry detergent were observed accessible to residents in care on or around 11/24/20. This posses an immediate health and safety risk to the residents in care.
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Type A
07/01/2022
Section Cited
CCR
87465(h)(2)
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Incidental Medical and Dental Care: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requrement has not been met as evidence by the Licensing agency
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During the visit 7/1/22, LPA conducted an inspection of the physical plant and did not observe medications accessible to the residents. No further corrections needed at this time.
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receiving a report from a credible source reporting that medications are left out on the shelf accessibe to residents in care. This poses an immediate 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: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20201203160048
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/01/2022
Section Cited
CCR
87307(e)
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Personal Accommodations and Services: Facilities providing services to residents shall assure the inaccessibility of swimming pools or similar bodies of water, when not in active use by residents, through fencing, covering or other means. Although backyard pool is fenced around its parameters, this
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During the visit 7/1/22, LPA conducted an inspection of the physical plant and observed the gate to the pool properly locked making it inaccessible to the residents in care. No further corrections needed at this time.
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requirement has not been met as evidenced by the Licensing agency receiving a report from a credible source reporting that the backyard pool was not properly locked & accessible. This poses an immediate 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: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4