197604283-10-9-2023-31-AS-NMAN-D5AUH2-20240515153511

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197604283
Report Date: 10/09/2023
Date Signed: 10/09/2023 04:33:32 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
10/03/2023 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20231003094310

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: 4	DATE:	10/09/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Maxie Hamilton		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility pool is in disrepair
Facility pool is accessible to residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to this facility to investigate the above allegations. LPA met with House Manager, Maxie Hamilton, and explained the reason for the visit.

--- Facility pool is in disrepair

It was alleged that the facility pool is filled with black water and residents would not be seen if they fell in. To investigate the allegation, on 10/09/2023 LPA conducted physical plant tour at around 11:00 AM, interviewed two (02) staff between 12:30 PM to 01:30 PM and interviewed three (03) residents from 1:30 PM to 2:30 PM. During the physical plant tour, LPA observed that water was clear and could see all the way to pool floor. During interviews with staff, all staff stated that the pool is cleaned every Wednesday and they have never observed black pool water.
(LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023

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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Control Number 31-AS-20231003094310

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: 10/09/2023

NARRATIVE

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During interviews with residents, all residents stated that they are not aware of how often the pool is clean, have never used the swimming pool and that they have never witnessed the swimming pool to be black in color.

Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

--- Facility pool is accessible to residents

It was alleged that there is no fence around the facility pool. To investigate the allegation, on 10/09/2023 LPA conducted a physical plant tour at around 10:00 AM and interviewed two (02) staff between 11:30 AM to 12:30 PM. During the physical plant tour, LPA observed that the swimming pool had a locked fence that meets height regulations rendering the pool inaccessible to residents. During interviews with staff, all staff stated that the pool has always had a fence around it and is always locked.

Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023

LIC9099 (FAS) - (06/04)

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