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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606229
Report Date: 09/15/2026
Date Signed: 09/16/2026 07:37:02 AM

Document Has Been Signed on 09/16/2026 07:37 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ELDER CREEK VILLA IIIFACILITY NUMBER:
197606229
ADMINISTRATOR/
DIRECTOR:		ALLEN RAPISURAFACILITY TYPE:
740
ADDRESS:28835 SECO CANYON ROADTELEPHONE:
(661) 713-0313
CITY:SAUGUSSTATE: CAZIP CODE:
91390
CAPACITY: 6CENSUS: 6DATE:
09/15/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Allen RapisuraTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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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)

Nichelle Gillyard
Tuesday Cabiness
DATE: 09/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ELDER CREEK VILLA III
FACILITY NUMBER: 197606229
VISIT DATE: 09/15/2026
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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.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Tuesday Cabiness
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/16/2026 07:37 AM - It Cannot Be Edited


Created By: Tuesday Cabiness On 09/15/2026 at 12:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELDER CREEK VILLA III
FACILITY NUMBER: 197606229

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2026
Section Cited
CCR
87555(b)(23)

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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
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POC cleared during the visit. Administrator properly wrapped and stored food in new ziploc bags.
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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.
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Type B
09/29/2026
Section Cited
CCR87506(b)

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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.
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Administrator AGREED to submit medical assessments that were missing for residents 4 & 5 by POC date.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Tuesday Cabiness
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2026


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 09/16/2026 07:37 AM - It Cannot Be Edited


Created By: Tuesday Cabiness On 09/15/2026 at 12:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELDER CREEK VILLA III
FACILITY NUMBER: 197606229

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/29/2026
Section Cited
CCR
87506(b)(15)

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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
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Administrator AGREED to submit the required documents for residents that were missing the needs and service plan and pre-admission appraisals.
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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.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Tuesday Cabiness
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2026


LIC809 (FAS) - (06/04)
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