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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606229
Report Date: 05/20/2025
Date Signed: 06/03/2025 10:32:52 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
05/17/2023 and conducted by Evaluator Tuesday Cabiness
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20230517154115
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: 5DATE:
05/20/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Allen RapisuraTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Resident developed a stage 3 pressure injury while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tuesday Cabiness met with Designee of the facility, Allen Rapisura and informed him the purpose of the visit, which is to finalize the above complaint allegation. On May 17, 2023, the Woodland Hills Regional South Adult and Senior Care Office received a complaint for the following allegation: “Resident developed a stage 3 pressure injury while in care.” On May 18, 2023, the complaint was referred to the Community Care Licensing Division’s (CCLD’s) Investigations Branch (IB), and assigned to Investigator Lorraine Patterson. The following was determined:

The initial investigation visit was conducted by LPA Tuesday Cabiness on 05/18/2023 from 330pm to 4pm to obtain resident and facility documents pertaining to the complaint. Between 05/30/2023 and 08/14/2023 IB Investigator Patterson conducted interviews with residents, staff, witnesses, and reviewed medical records, such as hospitalizations and home health documents involving resident # 1(R1). It was alleged R1 developed a stage 3 pressure injury on coccyx while in care. A review of medical documentation revealed, R1 was
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
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-20230517154115
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ELDER CREEK VILLA III
FACILITY NUMBER: 197606229
VISIT DATE: 05/20/2025
NARRATIVE
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This page of the report is being amended on 06/03/2025 to correct a typographical error made while typing this report. The findings remain the same..

receiving home health services for a stage 1 pressure injury on the buttock area prior to hospitalization. R1 was hospitalized from 04/07/2023 through 04/22/2023 for respiratory failure. On 04/21/2023, home health services were discontinued. R1 was re-hospitalized on 05/04/2023 for pneumonia and other medical conditions. At the time of admission, the hospital indicated there were no pressure injuries upon re-admission. On 05/06/2023 (two days later) medical records referenced a pressure injury on the coccyx, which was initially not staged and upon discharged was staged as a stage 2. On 05/19/2023 R1 was discharged to a skilled nursing facility with documentation of a stage 2 pressure injury near/on the coccyx.

The investigation identified inconsistencies and discrepancies in medical records from the hospital. Based on the documented timeline, R1 was hospitalized during the periods necessary for the development of a stage 3 pressure injury. Additionally, the allegation alleged a stage 3 pressure injury developed on/near R1’s buttock area which based on medical records from the hospital and home health has never been the case. Based on the investigation conducted by the Investigations Branch and the review of medical records, there is insufficient evidence to support the allegation that R1 developed a stage 3 pressure injury while in the care of the facility. Therefore, the allegation is unsubstantiated at this time.

An exit interview was conducted, and a copy of the report was provided.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2