<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606229
Report Date: 05/28/2022
Date Signed: 05/28/2022 08:22:00 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
03/23/2021 and conducted by Evaluator Michael Cava
COMPLAINT CONTROL NUMBER: 31-AS-20210323135928
FACILITY NAME:ELDER CREEK VILLA IIIFACILITY NUMBER:
197606229
ADMINISTRATOR:ALFREDO RAPISURAFACILITY TYPE:
740
ADDRESS:28835 SECO CANYON ROADTELEPHONE:
(661) 713-0313
CITY:SAUGUSSTATE: CAZIP CODE:
91390
CAPACITY:6CENSUS: 6DATE:
05/28/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Marianito IlaganTIME COMPLETED:
06:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not make hazardous items inaccessible to residents
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
In conjunction with a required annual inspection, Licensing Program Analyst (LPA) Michael Cava conducted a subsequent complaint visit to conclude the investigation regarding the above allegation. On March 2021, Community Care Licensing Division (CCLD) received a report via S223 alleging that on 03/17/2021, during an unannounced visit to the facility, it was observed that Clorox and glass cleaner were left unlocked and unattended in the bathroom cabinet. The reporting party also observed dishwasher pods and sharp kitchen tools unlocked and unattended underneath the kitchen sink. Although during the annual inspection, LPA observed cleaning supplies and sharps were locked and inaccessible to the residents in care, the report (S223) was made by a credible witness that observed these items during their visit to the home on or around 3/17/21. Therefore, based on their observation, the allegation is Substantiated. Citation issued on the LIC 9099D.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2022
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 2
Control Number 31-AS-20210323135928
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 III
FACILITY NUMBER: 197606229
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/28/2022
Section Cited
CCR
87309(a)
1
2
3
4
5
6
7
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 a report (S223) received
1
2
3
4
5
6
7
In conjunction with this complaint investigation, LPA conducted an annual insection. At the time of the inspection, disinfectantans, cleaning solutions and other items which can pose a danger if readily available were observed locked and inaccessible to the residents in care.
8
9
10
11
12
13
14
stating that during a visit on 3/17/21 the reporting party observed Clorox, glass cleaner, dishwasher pod and sharp kitchen tools acceessible to the residents. This posses an immediate health and safety risk to the residents in care.
8
9
10
11
12
13
14
No further correction needed at this time.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 05/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2