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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197604283
Report Date: 11/13/2024
Date Signed: 11/13/2024 02:17:20 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
11/08/2024 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20241108103624
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: DATE:
11/13/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:TIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Medications were not secured making them accessible to residents in care.
Chemicals were not locked up and were accessible to residents in care.
Knives were not locked up and accessible to residents in care.
Staff do not ensure solid waste was stored/disposed of appropriately.
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 Administrator, Maxie Hamilton, and explained the reason for the visit.

---Medications were not secured making them accessible to residents in care.
---Chemicals were not locked up and were accessible to residents in care.
---Knives were not locked up and accessible to residents in care.

It was alleged that medication drawer, cleansers in the laundry room, and a knife were unlocked and accessible to residents. To investigate the allegation, LPA conducted a physical plant tour at around 11:00a.m. and interviewed one (01) staff at around 11:30a.m.

(CONT. on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
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-20241108103624
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: 11/13/2024
NARRATIVE
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During the physical plant tour, LPA observed medications, sharps and chemicals unlocked, however, at the time staff were cooking, doing laundry and giving residents medications. During the interview, staff stated they are aware medications, chemicals and sharps were found unlocked during a visit by other parties and now keep everything locked when not in use.

Based on interviews, there is enough information to verify the allegation, therefore, the allegation is SUBSTANTIATED at this time.

---Staff do not ensure solid waste was stored/disposed of appropriately.

It was alleged that there are no lids on bathroom trash cans and living room trash can. To investigate the allegation, LPA conducted a physical plant tour at around 11:00a.m. and interviewed one (01) staff at around 11:30a.m. During the physical plant tour, LPA observed living room trash can with a lid, however, the bathroom trash did not have a lid. During the interview, staff stated they are aware of trash cans found without a lid during visit by other parties. Staff added they got a new one for the living room with a lid and the one in the bathroom will be taken out and replace with one that has a lid.

Based on interviews and observations, there is enough information to verify the allegation, therefore, the allegation is SUBSTANTIATED at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

No other health and safety hazards noted during the visit.

Exit interview conducted and a copy of the report was issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20241108103624
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: 11/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/16/2024
Section Cited
CCR
87309(a)
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Storage Space: 87309 (a) 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 is not as evidenced by;
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The Licensee will review regulation and submit a written letter certifying that, moving forward, they will ensure to follow and adhere to CCR Title 22 87309 Storage Space; The written letter must be sent to the LPA by the POC due date.
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Based on information obtained from a credible source and interviews, facility did not ensure cleaning solutions, sharps, medications were inaccessible to residents which poses a potential health, safety and personal rights risk to residents in care.
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Type B
11/16/2024
Section Cited
CCR
87465(h)(2)
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Incidental Medical and Dental Care: 87465(h)(2) 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.
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The Licensee will review regulation and submit a written letter certifying that, moving forward, they will ensure to follow and adhere to CCR Title 22 87465 Incidental Medical and Dental Care; The written letter must be sent to the LPA by the POC due date.
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This requirement is not as evidenced by; Based on information obtained from a credible source and interviews, facility did not ensure medications were inaccessible to residents which poses a potential health, safety and personal rights 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.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20241108103624
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: 11/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/16/2024
Section Cited
CCR
87303(f)(3)
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Maintenance and Operation 87303(f)(3) All containers,….used for storage of solid wastes shall have tight-fitting covers… This requirement is not as evidenced by;
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The Licensee will review regulation and submit a written letter certifying that, moving forward, they will ensure to follow and adhere to CCR Title 22 87303 Maintenance and Operation; The written letter must be sent to the LPA by the POC due date.
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Based on information obtained from a credible source, interviews and observations, facility did not ensure all containers used for solid waste storage have tight-fitting lids which poses a potential health, safety and personal rights 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.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4