Elder Creek Villa III

Type of visit: Required - 1 Year

LPA Tuesday Cabiness conducted a required annual inspection at the facility. Upon arrival, LPA met with caregiver Mario Ilagan, who was informed of the purpose of the visit. LPA was granted entry and observed additional staff members on duty. Caregiver Mario contacted Administrator Allen Rapisura, who arrived shortly thereafter and was also informed of the visit's purpose. The current census is (6) residents. The following required licensing documents were visibly posted: facility license, rights of resident council, grievance/complaint procedures, emergency disaster plan, resident bill of rights, personal rights, and neighborhood complaint procedures. Physical Plant Tour: A comprehensive tour of the interior and exterior of the facility was conducted. The following areas were inspected: Kitchen/Food Supply: The food service area met Licensing requirements: a seven (7)-day supply of nonperishable food and a two (2)-day supply of perishable food. Food was not wrapped and stored properly. Kitchen appliances were in working condition. Chemicals, household supplies, knives, and medications were locked and secured in the kitchen, garage, and closet. Living/Dining/Family/Staff Areas: All indoor passageways were clear of obstructions. Rooms were clean, adequately furnished, and comfortable for residents. Bedrooms: The facility contains seven (7) bedrooms and two (2) bathrooms. Six (6) residents occupy the facility; one (1) bedroom is designated for staff use. (Cont'd on LIC809C) Bathrooms: Bathrooms were clean and functioning properly. Grab bars were appropriately installed in toilets and showers, with non-skid mats. Hot water temperature was within regulation. Surrounding Grounds: Smoke alarms and carbon monoxide detectors were tested and found to be operational. The fire extinguisher was fully charged. No visible hazards were observed; indoor and outdoor passageways were unobstructed. The backyard featured a covered patio with appropriate seating for residents. The swimming pool was securely fenced and locked at the time of the visit. Record Review: Resident Records: (R1-R6) was missing needs and service plan and pre-admission appraisal. R4 & R5 was missing physician report. Staff Records: No discrepancies were observed. Medications: Medication storage and records were reviewed. An exit interview, citations, appeal rights, and a copy of the report was given to the Administrator.the state’s words, verbatim · CDSS document, Sep 15, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(23) · Plan of correction due date: Sep 15, 2026

General food service requirements: (b)The following food service requirements shall apply: (23)All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement was not met, evidenced by, based on food inspection, LPA observed food not stored or properly wrapped. Frozen food was open. This is a health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: POC cleared during the visit. Administrator properly wrapped and stored food in new ziploc bags.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(b) · Plan of correction due date: Sep 29, 2026

Residents records: (b)Each resident’s record shall contain at least the following information: (10)Reports of the medical assessment specified in Section 87458, Medical Assessment, and of any special problems or precautions.the state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Administrator AGREED to submit medical assessments that were missing for residents 4 & 5 by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(b)(15) · Plan of correction due date: Sep 29, 2026

Resident records: (b) Each resident’s record shall contain at least the following information: (15)The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. This requirement was not met, evidenced by, during the annual inspection, LPA observed all (6) residents missing pre-admission appraisals and needs and service plans. This is a potential health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Administrator AGREED to submit the required documents for residents that were missing the needs and service plan and pre-admission appraisals.

Allegation investigated: Resident developed a stage 3 pressure injury while in care

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 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.the state’s words, verbatim · CDSS document, May 20, 2025 · control 31-AS-20230517154115

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a case management visit to deliver the final complaint investigation report for complaint control number 31-AS-20230517154115. During the visit, LPA met with the facility designee, Allen Rapisura, to explain the reason for the citation issued today. It was revealed to LPA that the facility staff did not have the required licensing documentation, specifically the LIC 503 Health Screening Report, which is mandatory for the change of administrator. Allen informed LPA that he had undergone a TB test on 05/19/2025, which returned a positive result. He further stated he was scheduled to receive a chest X-ray today to further evaluate the TB test results. LPA explained that the Health Screening Report is required prior to working in a licensed facility, as stipulated by licensing regulations. Allen reported he was unable to locate his previous health screening and was attempting to obtain a current one. Due to the absence of a valid or current health screening, and the recent positive TB test result, LPA advised that a citation would be issued for noncompliance with licensing requirements. LPA emphasized that this represents a potential health and safety risk to both staff and residents, as well as to LPA during the visit. LPA instructed Allen not to enter the facility until a negative test result is obtained and submitted to the Department. An exit interview was conducted, citation issued, appeal rights, and a copy of the report was provided to the facility.the state’s words, verbatim · CDSS document, May 20, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87412(a)(11) · Plan of correction due date: May 21, 2025

Personnel Records Personnel records: (a)Th e licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11)A health screening as specified in Section 87411, Personnel Requirements - General. This requirement was not met, evidenced by, based on, staff Allen, did not have a current health screening during today's visit, which is a health and safety risk to residents and staff in care.the state’s words, verbatim · CDSS document, May 20, 2025

Plan of correction: Staff Allen Rapisura will submit to LPA a current health screening report, showing negative or positve test results. Allen was informed to not return to the facility until he has negative test results and it is submitted to LPA.

Type of visit: Required - 1 Year

LPA Tuesday Cabiness conducted a required annual inspection at the facility. Upon arrival, LPA met with caregiver Mario Ilagan, who was informed of the purpose of the visit. LPA was granted entry and observed two additional staff members on duty. Caregiver Mario contacted Administrator Allen Rapisura, who arrived shortly thereafter and was also informed of the visit's purpose. The current census is five (5) residents. The following required licensing documents were visibly posted: facility license, rights of resident council, grievance/complaint procedures, emergency disaster plan, resident bill of rights, personal rights, and neighborhood complaint procedures. Physical Plant Tour: A comprehensive tour of the interior and exterior of the facility was conducted. The following areas were inspected: Kitchen/Food Supply: The food service area met Licensing requirements: a seven (7)-day supply of nonperishable food and a two (2)-day supply of perishable food. Food was wrapped and stored properly. Food preparation and storage areas were clean and pest-free. Kitchen appliances were clean and in working condition. The kitchen had been remodeled with freshly painted cabinets and new counter tops. Walls and floors were clean. Chemicals, household supplies, knives, and medications were locked and secured in the kitchen, garage, and closet. Living/Dining/Family/Staff Areas: All indoor passageways were clear of obstructions. Rooms were clean, adequately furnished, and comfortable for residents. Bedrooms: The facility contains seven (7) bedrooms and two (2) bathrooms. Six (6) residents occupy the facility; one (1) bedroom is designated for staff use. During the previous inspection on 07/09/2024, LPA observed a newly constructed room in the garage area for staff use. The facility later removed the construction and submitted photos to LPA. Since the additional room was not approved by Licensing and did not match the original facility sketch, Administrator Allen initiated the process to obtain proper approval and fire clearances to modify the license for five (5) non-ambulatory bedrooms and one (1) staff bedroom. The room lacked prior approval from the city and fire department. However, since the last annual visit, the Administrator has remained in regular communication with both departments regarding code compliance and licensing updates. During this visit, LPA received emails from the Administrator demonstrating what is needed to obtain final approvals. Once all approvals are secured, the Administrator will submit an updated LIC 200 and new facility sketch to reflect the structural changes and fire clearance. Bathrooms: Bathrooms were clean and functioning properly. Grab bars were appropriately installed in toilets and showers. Hot water temperature was within regulation. Surrounding Grounds: Smoke alarms and carbon monoxide detectors were tested and found to be operational. The fire extinguisher was fully charged. No visible hazards were observed; indoor and outdoor passageways were unobstructed. The backyard featured a covered patio with appropriate seating for residents. The swimming pool was securely fenced and locked at the time of the visit. Record Review: Resident Records: Resident #1 (R1 & R2) had missing documentation due to staff misplacement. Staff Records: No discrepancies were observed. Medications: Medication storage and records were reviewed. But, the facility has accepted (2) additional hospice residents, when there waiver is only approved for (2). An exit interview, citations, appeal rights, and a copy of the report was given to the Administrator.the state’s words, verbatim · CDSS document, May 5, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Tuesday Cabiness, conducted a case management in regards to additional documentation that is needed for resident # 1 (R1). Also during the visit, LPA observed the Administrator/Licensee's administrator certificate expired 01/16/2025. LPA was informed that Allen, the son of the Administrator would be taking responsibility and becoming the Administrator for the facility. LPA sent a list of documents and information that is needed in order to make the changes. A citation will be issued for an expired Administrator's certificate. Exit interview, citation, appeal rights, and copy of report provided.the state’s words, verbatim · CDSS document, May 5, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87407(k) · Plan of correction due date: May 12, 2025

Administrator Recertification Requirements: (k) Whenever a certified administrator assumes or relinquishes responsibility for administering a residential care facility for the elderly, he or she shall provide written notice, within thirty (30) days, to: This requirement was not met, evidenced by, during today's annual inspection, LPA observed the current Administrator's certificate expired 01/16/2025. LPA was informed the son will be taking over as Administrator for the facility.the state’s words, verbatim · CDSS document, May 5, 2025

Plan of correction: Allen Rapisura will submit the required documents needed to change the current Administrator to the new one, who will be the son.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a required annual inspection. LPA met with caregiver Mario Ilagan, who was informed the reason of the visit. LPA was allowed to enter, and observed residents in the living room, and (2) additional staff on duty. Caregiver contacted Administrator's son, Allen Rapisura who was informed the reason of the visit. Administrator Alfredo Rapisura was contacted, and LPA spoke to him over the phone; he was also informed the reason of the visit. Allen Rapisura arrived shortly after. Also, caregiver Allen's family arrived with wife and (2) daughters, and during personnel summary check, the wife was not associated or fingerprint cleared. A civil penalty will be issued for not having fingerprint clearance or association. 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, and COVID related signs visibly posted. A physical plant tour of the facility inside and outside was conducted. The following common areas: living, dining, kitchen, family, resident/staff rooms, and bathrooms 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 not properly stored in a healthy manner. Food storage and preparation areas were opened and not clean which could lead accessible to pests. Appliances were functional and not clean. Walls were dirty in the kitchen, hallway and bathroom. Chemicals, household supplies, and knives, and medication was locked and secured in the kitchen and garage area. Living/dining/family/staff area: All indoor passageways were free from obstruction; and all areas were clean and appropriately furnished for resident’s comfort. Bedrooms: The facility has six (7) bedrooms and (2) bathrooms currently occupying six (6) residents; with one (1) bedroom is designated for staff use. During last year's inspection on 05/18/2023, LPA observed in the garage area, an additional built new room for staff. The new building was not approved by Licensing and did not match the original facility sketch that was originally submitted to Licensing. A citation was issued; and facility was to submit there plan of correction. During today's visit, LPA observed the same additional room, which was called a "break room" for staff, but it did not have approval by the city to be built. An additional citation for the same deficiency will be issued; due to altering the existing building without approval from Licensing, and not obtaining a proper fire clearance for bedridden residents. Also LPA observed resident # 1 (R1) who was admitted to the facility on 07/04/2023, with a prohibited health condition, a colostomy bag. An immediate $500 civil penalty will be assessed for retaining residents that are bed-ridden and not having a proper fire clearance. An additional $500 will be assessed due to the facility retaining a resident with a prohibited health condition. 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 checked. 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. There were no visible hazards, and passageways were free from obstruction inside of the facility. 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. Record Review: LPA reviewed (5) resident files, and observed R1-R5 were missing important Licensing documents, such as physician reports, needs and service plans, functional capabilities, re and pre-appraisal documents, and residents diagnosed with dementia, without a current physician report. Staff file review: Staff # 2 is missing a health screening report; other documents reviewed and checked. This poses a potential health and safety risk to residents in care. Medication review: Exit interview, citations, immediate civil penalty, appeal rights and copy of report provided. Total amount of civil penalties issued during this visit $1100.00the state’s words, verbatim · CDSS document, Jul 9, 2024