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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197604283
Report Date: 05/13/2021
Date Signed: 05/13/2021 02:01:20 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
05/06/2021 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20210506153931
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:
05/13/2021
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Jessie ManuelTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff are not following proper infection control procedures.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced initial complaint visit to investigate the allegations above. LPA met with facility staff and explained the reason for this visit.
LPA spoke with the administrator Alfredo Rapisura by telephone and explained the reason for this visit.

Staff are not following proper infection control procedures.
It is alleged that facility does not properly screen visitors prior to entry to the facility or take any temperatures prior to visitors entering the facility. Upon entry to the facility LPA was not screened or did anyone take LPA's temperature. LPA was also informed the facility did not have any more personal protection equipment (PPE). Based upon the information obtained through observation and interviews this allegation is deemed Substantiated.
All deficiencies cited on LIC 9099 D. Appeal Rights explained. Exit Interview conducted. Copy of report emailed for signature.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 31-AS-20210506153931
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: 05/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2021
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All facilities-To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement was not met as evidenced by:
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Administrator shall have an in-service training with staff on the importance of screening all visitors and taking temperatures of everyone entering the facility. Copy of the in-service sign in sheet will be submitted to clear the citation.
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Based on observation facility staff failed to screen and take temperature of LPA who was visiting and of other people who have entered the facility. This poses a potential health and safety 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.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021
LIC9099 (FAS) - (06/04)
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