197606229-7-9-2024-31-AS-TCAS-D6ZUD7-20240709152905

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606229
Report Date: 07/09/2024
Date Signed: 07/09/2024 03:31:55 PM

Document Has Been Signed on 07/09/2024 03:31 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ELDER CREEK VILLA III		FACILITY NUMBER:	197606229
ADMINISTRATOR:	ALFREDO RAPISURA		FACILITY TYPE:	740
ADDRESS:	28835 SECO CANYON ROAD		TELEPHONE:	(661) 713-0313
CITY:	SAUGUS	STATE: CA	ZIP CODE:	91390
CAPACITY:	6	CENSUS: 6	DATE:	07/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Allen Rapisura		TIME COMPLETED:	04:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Tuesday Cabiness conducted a required annual inspection. LPA met with caregiver Mario Ilagan, who was informed the reason of the visit. LPA was allowed to enter, and observed residents in the living room, and (2) additional staff on duty. Caregiver contacted Administrator's son, Allen Rapisura who was informed the reason of the visit. Administrator Alfredo Rapisura was contacted, and LPA spoke to him over the phone; he was also informed the reason of the visit. Allen Rapisura arrived shortly after. Also, caregiver Allen's family arrived with wife and (2) daughters, and during personnel summary check, the wife was not associated or fingerprint cleared. A civil penalty will be issued for not having fingerprint clearance or association. The current census is six (6). Facility license, rights of resident council, grievance/complaint procedures, emergency disaster plan, resident bill of rights, personal rights, and neighborhood complaint procedures, and COVID related signs visibly posted.

A physical plant tour of the facility inside and outside was conducted. The following common areas: living, dining, kitchen, family, resident/staff rooms, and bathrooms were inspected to ensure the facility was in compliance with Title 22 Regulations:

Kitchen/Food Supply: Food service area had Licensing requirement of (7) day nonperishable, and (2) day perishable. Food was not properly stored in a healthy manner. Food storage and preparation areas were opened and not clean which could lead accessible to pests. Appliances were functional and not clean. Walls were dirty in the kitchen, hallway and bathroom. Chemicals, household supplies, and knives, and medication was locked and secured in the kitchen and garage area.

Living/dining/family/staff area: All indoor passageways were free from obstruction; and all areas were clean and appropriately furnished for resident’s comfort. Bedrooms: The facility has six (7) bedrooms and (2) bathrooms currently occupying six (6) residents; with one (1) bedroom is designated for staff use.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELDER CREEK VILLA III	FACILITY NUMBER: 197606229
	VISIT DATE: 07/09/2024

NARRATIVE

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During last year's inspection on 05/18/2023, LPA observed in the garage area, an additional built new room for staff. The new building was not approved by Licensing and did not match the original facility sketch that was originally submitted to Licensing. A citation was issued; and facility was to submit there plan of correction. During today's visit, LPA observed the same additional room, which was called a "break room" for staff, but it did not have approval by the city to be built. An additional citation for the same deficiency will be issued; due to altering the existing building without approval from Licensing, and not obtaining a proper fire clearance for bedridden residents. Also LPA observed resident # 1 (R1) who was admitted to the facility on 07/04/2023, with a prohibited health condition, a colostomy bag. An immediate $500 civil penalty will be assessed for retaining residents that are bed-ridden and not having a proper fire clearance. An additional $500 will be assessed due to the facility retaining a resident with a prohibited health condition.

Bathrooms: The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the toilet and shower. The hot water temperature was checked. There was enough clean linen available in stock at the cabinet. Surrounding Grounds: Smoke alarms and carbon monoxide detectors were tested and operating properly. Fire extinguisher is fully charged. There were no visible hazards, and passageways were free from obstruction inside of the facility. Backyard has a covered patio with appropriate seating for residents when sitting outside. The swimming pool is appropriately fenced and was observed to be locked during visit.

Record Review: LPA reviewed (5) resident files, and observed R1-R5 were missing important Licensing documents, such as physician reports, needs and service plans, functional capabilities, re and pre-appraisal documents, and residents diagnosed with dementia, without a current physician report. Staff file review: Staff # 2 is missing a health screening report; other documents reviewed and checked. This poses a potential health and safety risk to residents in care. Medication review:

Exit interview, citations, immediate civil penalty, appeal rights and copy of report provided.

Total amount of civil penalties issued during this visit $1100.00

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/09/2024 03:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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: 07/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87208(d)

Plan of Operation

(d) A licensee who accepts or retains bedridden persons shall include additional information in the plan of operation as specified in Section 87606(f). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on today's annual inspection and observation and record review for resident # 1 and 4, both are bedridden, and the facility does not have a fire clearance for bedridden clients. This poses an immediate health and safety risk to resident in care.
	POC Due Date: 07/10/2024
	Plan of Correction
1 2 3 4	Caregiver Allen Rispura will submit LIC200 application and possible fee submitted to Licensing to obtain approval and fire clearance for facility due to have bedridden clients.

Type A

Section Cited

CCR

87202(a)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on today's annual inspection and observation and record review for resident # 1 and 4, both are bedridden, and the facility did not have a fire clearance for bedridden clients. This poses an immediate health, safety or personal rights risk to persons in care. An immediate civil penalty in the amount of $500 will be fined.
	POC Due Date: 07/10/2024
	Plan of Correction
1 2 3 4	Caregiver Allen Rispura will submit LIC200 application, possible fee, and new facility sketch submitted to Licensing to obtain approval and fire clearance for facility due to have bedridden clients and the room built in the garage for staff, used a a break room.

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: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/09/2024 03:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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: 07/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)(2)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on today's annual inspection and observation and record review for resident # 1 and 4, both are bedridden, and the facility did not have a fire clearance for bedridden clients. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/10/2024
	Plan of Correction
1 2 3 4	POC

Type A

Section Cited

CCR

87412(a)(13)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on annual inspection, the Administrator's son's family, wife visited the facility, and according to the personnel summary, the wife did not have a fingerprint clearance or was associated to the facility. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/10/2024
	Plan of Correction
1 2 3 4	POC

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: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/09/2024 03:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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: 07/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(23)

General Food Service Requirements

(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on today's annual inspection for the facility's food supply, LPA observed food to be not properly wrapped, opened, old and freezer burned. This is a immediate health and safety risk to residents in care. POC cleared, food was discarded.
	POC Due Date: 07/09/2024
	Plan of Correction
1 2 3 4	POC cleared, food was discarded

Type A

Section Cited

CCR

87555(b)(28)

General Food Service Requirements

(b) The following food service requirements shall apply: (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on today's annual inspection for the facility's food supply, LPA observed food to be not properly wrapped, opened, old and freezer burned. This is a immediate health and safety risk to residents in care. POC cleared, food was discarded
	POC Due Date: 07/09/2024
	Plan of Correction
1 2 3 4	POC cleared during visit. Food was discarded

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: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/09/2024 03:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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: 07/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87457(c)

Pre-Admission Appraisal

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on today's annual inspection and record review, all residents 1-5, per LIC858, were missing important and required licensing documents, such as physician reports, re and pre-appraisal, needs and service plan, functional capabilities documents. This is a potential health and safety risk to residents in care.
	POC Due Date: 07/23/2024
	Plan of Correction
1 2 3 4	Caregiver will review all resident files, and will make sure all Licensing requirement documents are in the files. POC wil be emailed to LPA.

Type B

Section Cited

CCR

87457(c)(1)

Pre-Admission Appraisal

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on today's annual inspection and record review, all residents 1-5, per LIC858, were missing important and required licensing documents, such as physician reports, re and pre-appraisal, needs and service plan, functional capabilities documents. This is a potential health and safety risk to residents in care.
	POC Due Date: 07/23/2024
	Plan of Correction
1 2 3 4	Caregiver will review all resident files, and will make sure all Licensing requirement documents are in the files. POC wil be emailed to LPA.

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: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

LIC809 (FAS) - (06/04)

Page: 6 of 8

Document Has Been Signed on 07/09/2024 03:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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: 07/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87455(c)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	(c) No resident shall be accepted or retained if any of the following apply: This requirement was not met, evidenced by, during today's annual inspection, LPA observed the facility retained (2) residents that were bedridden and one had a prohibited health condition (colostomy) bag, resident#1. This is an immediate health and safety risk to residents in care and an immediate civil penalty will be assessed and an immediate $500.00 civil penalty will be assessed.
	POC Due Date: 07/10/2024
	Plan of Correction
1 2 3 4	Caregiver Allen AGREED to submit to LPA training will be provided by nurse Rebecca and staff inservice documents will be submitted to LPA.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

LIC809 (FAS) - (06/04)

Page: 7 of 8

Document Has Been Signed on 07/09/2024 03:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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: 07/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87305(b)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	This requirement is not met as evidenced by: Based on today's physical plant inspection, LPA observed the facility built an additional sleeping room in the garage for staff. LPA reviewed the original facility sketch, and the additional room was not included when the application was submitted. This is a potential health and safety risk to residents in care.
	POC Due Date: 07/23/2024
	Plan of Correction
1 2 3 4	The Administrator AGREED to contact the City of Santa Clarita by the POC date and will submit documentation of the scheduled visit and contact to inspect the building and issue an approval or denial of the building.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

LIC809 (FAS) - (06/04)

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