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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197604283
Report Date:
02/28/2022
Date Signed:
02/28/2022 12:50:27 PM
Document Has Been Signed on
02/28/2022 12:50 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 II
FACILITY NUMBER:
197604283
ADMINISTRATOR:
RAPISURA, ALFREDO
FACILITY TYPE:
740
ADDRESS:
21113 ELDER CREEK DR
TELEPHONE:
(661) 713-0313
CITY:
SAUGUS
STATE:
CA
ZIP CODE:
91350
CAPACITY:
6
CENSUS:
6
DATE:
02/28/2022
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
10:30 AM
MET WITH:
Maxie Hamilton
TIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced required annual visit. LPA met with facility staff and explained the reason for this visit.
LPA began a physical plant tour at approximately 10:35am. Facility has six bedrooms and two bathrooms. LPA observed all bedrooms to have the appropriate furniture. All bathrooms had grab bars and non skid material. LPA checked the kitchen for the ability to prepare and store food. LPA observed there to be a sufficient amount of perishable and non perishable food. LPA observed knives and sharp objects to be locked away and inaccessible. LPA observed all common areas to be appropriately furnished. LPA observed the smoke detectors and carbon monoxide were observed to be working properly. LPA checked the backyard of the facility which has a pool that is locked and inaccessible from residents. During the visit LPA observed residents to be watching television in the common areas. Exit Interview conducted.
SUPERVISORS NAME
:
Cassandra Harris
LICENSING EVALUATOR NAME
:
Wendell Smith
LICENSING EVALUATOR SIGNATURE
:
DATE:
02/28/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/28/2022
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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