<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606229
Report Date: 09/21/2021
Date Signed: 09/21/2021 01:40:28 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
05/03/2021 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20210503150117
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: 6DATE:
09/21/2021
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Aurea Manalastas - StaffTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff mishandle residents medications while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit to further investigate the above allegation. LPA met with staff Aurea Manalastas who called the administrator. The administrator was not able to come due to personal reason and designated staff Ms. Manalastas to sign the report.

LPA conducted physical plant tour at 9:30 AM and interviewed additional staff at 10:35 AM. LPA's observation during virtual visit on 05/05/21 at 9:25 AM and today's physical plant tour at 9:30 AM, revealed that the facility has a Living room and a TV room. The TV room is approximately 25 feet away from the main entrance door and the TV room seats are approximately 15 feet away from the Living room. The TV room and dining room is divided by a wall in between the Living Room and TV room. Further, during both visits, the residents did not hang out in the Living Room where the medications were seen. LPA's interview with staff on 05/05/21 at 10:50 AM and today at 10:35 AM, revealed that residents only hang out in the TV room and the Living room is only being used as a reception area for family and/or visitors. (continued on LIC 9099)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
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-20210503150117
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 III
FACILITY NUMBER: 197606229
VISIT DATE: 09/21/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(continued from LIC 9099)

Further interview with staff revealed that during the time that the medications were allegedly left on the Living Room table, Staff #1 (S1) was preparing the residents' medication for dinner at 4:00 PM in the Living Room and only opened the door for the visitor to come in but did not actually leave the medication on the table for long.

Based on the information gathered during this and prior visit, the allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2