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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197604283
Report Date: 03/15/2024
Date Signed: 03/15/2024 03:42:47 PM

Unsubstantiated


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
10/03/2023 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20231003094310
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: 5DATE:
03/15/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Maxie HamiltonTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Staff did not have resident's authorized representative sign an admissions agreement.
Staff inappropriately recorded resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to this facility to investigate the above allegations. LPA met with House Manager, Maxie Hamilton, and explained the reason for the visit.

--- Staff did not have resident's authorized representative sign an admissions agreement

It was alleged that responsible party never filled out any paperwork or given an Admissions Agreement. To investigate the allegation, on 10/09/2023 LPA interviewed two (02) staff between 12:30 PM to 01:30 PM. During interviews with staff, S1 stated that Resident #1 (R1) was in the facility for less than 24 hours. R1 was brought in on 09/05/2023 at around 08:00 PM as they were in desperate need to find placement. S1 added R1’s responsible party arrived shortly after and refused to sign any documents.
(CONT. on LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
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-20231003094310
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
VISIT DATE: 03/15/2024
NARRATIVE
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S1 also stated R1 refused medications and the responsible party came the following morning, called an ambulance at around 09:00 AM and never returned. During interview with other parties, they stated facility never provided the Admissions Agreement or any other paperwork.

Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

--- Staff inappropriately recorded resident

It was alleged that staff recorded Resident #1 (R1). To investigate the allegation, on 10/09/2023 LPA conducted a physical plant tour at around 10:00 AM and interviewed two (02) staff between 11:30 AM to 12:30 PM and interviewed three (03) residents from 1:30 PM to 2:30 PM. During the physical plant tour, LPA did not observe any cameras or recording devices in the facility. During interviews with staff, all staff stated they do not record residents. During interviews with residents, all residents stated that they are aware of ever being recorded in the facility. During interviews with other parties, they stated they were shown videos of the R1 sleeping on the couch.

Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards noted during the visit.

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2