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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606229
Report Date: 05/28/2022
Date Signed: 05/30/2022 11:26:27 PM

Document Has Been Signed on 05/30/2022 11:26 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: 6DATE:
05/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Marianito IlaganTIME COMPLETED:
06:00 PM
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Licensing Program Analyst (LPA) Michael Cava conducted an annual infection control inspection. LPA met with the caregiver, Marianito Ilagan and advised him of the visit. The current census is six (6). Facility license, rights of resident council, grievance/complaint procedures, emergency disaster plan, resident bill of rights, personal rights, and neighborhood complaint procedures visibly posted.

A physical plant tour of the facility inside and outside was conducted. The following common areas: living, dining, kitchen, resident bedrooms, bathrooms, and staff room 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. Snacks and beverages are available for clients. Frozen foods are properly wrapped and stored appropriately. 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.

Living/dining/family/staff area: All indoor passageways were free from obstruction; inside temperature was comfortable and set at 73 degrees, with adequate lighting, and all areas were clean and appropriately furnished for resident’s comfort.

Bedrooms: The facility has six (6) bedrooms and two (2) bathrooms currently occupying six (6) residents. One additional (1) bedroom is designated for staff use. The facility is fire cleared for five (5) non-ambulatory residents and one ambulatory only on Room #2, hospice waiver for two (2).

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 05/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2022
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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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: 05/28/2022
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Staff Rooms: Staff room was observed to be locked, located adjacent to the laundry room. No medications are observed in the staff room.

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 measured at 111°F. Towels and washcloths are not shared. There was enough clean linen available in stock at the cabinet.

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. There were no visible hazards, and passageways were free from obstruction inside of the facility.

The backyard: The 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.

The garage is currently being used as frozen food, tools and other supplies storage.

Laundry room is located in the room on the way to the garage. Laundry detergents, cleaning agents and other toxins are stored in a locked cabinet in the garage.

Pursuant to title 22, division 6, chapter 8, there were no deficiencies observed during the day's inspection. The administrator was advised and a copy of this report given.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2022
LIC809 (FAS) - (06/04)
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