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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606229
Report Date: 05/18/2023
Date Signed: 05/18/2023 03:22:39 PM


Document Has Been Signed on 05/18/2023 03:22 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 IIIFACILITY NUMBER:
197606229
ADMINISTRATOR:ALFREDO RAPISURAFACILITY TYPE:
740
ADDRESS:28835 SECO CANYON ROADTELEPHONE:
(661) 713-0313
CITY:SAUGUSSTATE: CAZIP CODE:
91390
CAPACITY:6CENSUS: 4DATE:
05/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Alfredo RapisuraTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tuesday Cabiness a required annual inspection. LPA met with the Administrator Alfredo Rapisura and informed him the reason of the visit. The current census is six (4). 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 properly stored in a healthy manner. Food storage and preparation areas were clean and inaccessible to pests. Appliances were functional and clean. 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 (4) residents; with one (1) bedroom is designated for staff use. LPA also observed in the garage area, and additional built new room for staff. The new building was not approved by Licensing and does not match the original facility sketch that was originally submitted to Licensing. A citation will be issued due to altering the existing building without approval from Licensing. 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.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2023
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 III
FACILITY NUMBER: 197606229
VISIT DATE: 05/18/2023
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Surrounding Grounds: Smoke alarms and carbon monoxide detectors were tested and operating properly. Fire extinguisher is fully charged. The facility is equipped with fire sprinkler, that is connected to the fire department. 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 (1) resident file, and observed R1 with dementia to not have current physician report. The report reviewed was dated 07/2019. Staff file review: Staff #1 (S1) did not have current CPR/First Aid certificate. It was expired in 2021. This poses a potential health and safety risk to residents in care.

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

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/18/2023 03:22 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
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: 05/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)


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 additonal room was not included when the application was submitted. This is a potential health and safey risk to residents in care.
Deficient Practice Statement
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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 additonal room was not included when the application was submitted. This is a potential health and safey risk to residents in care. This poses as a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2023
Plan of Correction
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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.
Type B
Section Cited
CCR
87705(c)(5)


This requirement is not met as evidenced by: Based on resident record review, LPA observed resident #1 (R1) not having a current physician report, who is diagnosed with dementia. The last report observed was date 07/2019.
Deficient Practice Statement
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Based on resident record review, LPA observed resident #1 (R1) not having a current physician report, who is diagnosed with dementia. The last report observed was date 07/2019. This poses as a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2023
Plan of Correction
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The Administrator AGREED to submit an updated physician report for R1 by POC date.
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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 05/18/2023 03:22 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
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: 05/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA observed staff #1 (S1) not to have current first aid or CPR training. Certifcate had expired 2/2021. This poses as a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/25/2023
Plan of Correction
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Administrtator has AGREED to submit current CPR/First Aid certifcate for staff # 1.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4