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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604283
Report Date: 02/17/2024
Date Signed: 02/17/2024 12:37:26 PM


Document Has Been Signed on 02/17/2024 12:37 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 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:
02/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:29 AM
MET WITH:Maxie HamiltonTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Abeye Duguma met with house manager Maxie Hamilton for a Required One (01) Year visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at 08:30 AM and the following was noted:

There is one entrance being utilized at the facility. The facility has a total of six (06) bedrooms and two (02) bathrooms. The facility is fire cleared for six (06) non-ambulatory. The facility is currently occupying six (06) residents.

The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility has a swimming pool with appropriate locked fencing. The garage is currently being used for storage and office. Laundry is located near the kitchen area. Laundry detergents, cleaning agents and other toxins are locked away.

Kitchen is sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are 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 72°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguisher is located near the kitchen, fully charged and last purchased 09/06/2023.

(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: 02/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2024
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 II
FACILITY NUMBER: 197604283
VISIT DATE: 02/17/2024
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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 116.1°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.

No health and safety hazards noted during the visit.

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: 02/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2024
LIC809 (FAS) - (06/04)
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