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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606229
Report Date: 05/05/2025
Date Signed: 05/05/2025 02:08:15 PM

Document Has Been Signed on 05/05/2025 02:08 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ELDER CREEK VILLA IIIFACILITY NUMBER:
197606229
ADMINISTRATOR/
DIRECTOR:		ALFREDO RAPISURAFACILITY TYPE:
740
ADDRESS:28835 SECO CANYON ROADTELEPHONE:
(661) 713-0313
CITY:SAUGUSSTATE: CAZIP CODE:
91390
CAPACITY: 6CENSUS: 5DATE:
05/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Allen RapisuraTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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
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.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Tuesday Cabiness
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2025
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)
Page: 2 of 5
Document Has Been Signed on 05/05/2025 02:08 PM - It Cannot Be Edited


Created By: Tuesday Cabiness On 05/05/2025 at 01:21 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: 05/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87204(a)
Limitations -Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on today's observations and recored review, the facility has a hospice waiver for (2); but has accepted an additonal (2) residents without requesting for an exception or hospice waiver increase; which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2025
Plan of Correction
1
2
3
4
Administrator Allen will first submit a hospice exception for the other (2) residents that are not approved to be on hospice at this time.
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations and record review (2) residents incomplete Licensing documents in files; which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2025
Plan of Correction
1
2
3
4
Administrator will submit Licensing records for resident 1 # 2 by POC date: admission agreement, physician report, TB results, weight, needs and service plan, client personal property document, physician report
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Troy Agard
NAME OF LICENSING PROGRAM MANAGER:
Tuesday Cabiness
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/05/2025 02:08 PM - It Cannot Be Edited


Created By: Tuesday Cabiness On 05/05/2025 at 01:21 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: 05/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(h)(1)
Hospice Care for Terminally Ill Residents
(h) For each terminally ill resident receiving hospice services in the facility, the licensee shall maintain the following in the resident's record: (1) A written request for acceptance or admittance to or retention in the facility while receiving hospice services, along with any advance directive and/or request regarding resuscitative measures form executed by the resident or (in certain instances) the resident's Health Care Surrogate Decision Maker.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on today's observations and recored review, the facility has a hospice waiver for (2); but has accepted an additonal (2) residents without requesting for an exception or hospice waiver increase; which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2025
Plan of Correction
1
2
3
4
Administrator Allen will first submit a hospice exception for the other (2) residents that are not approved to be on hospice at this time.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Troy Agard
NAME OF LICENSING PROGRAM MANAGER:
Tuesday Cabiness
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/05/2025
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

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.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Tuesday Cabiness
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5