197603663-2-16-2023-29-AS-DPEA-CRATJ6-20230427144548

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603663
Report Date: 02/16/2023
Date Signed: 02/16/2023 01:53:44 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/10/2023 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20230210094042

FACILITY NAME:	SEPULVEDA RESIDENTIAL		FACILITY NUMBER:	197603663
ADMINISTRATOR:	MARK SAMUEL		FACILITY TYPE:	735
ADDRESS:	8025 SEPULVEDA		TELEPHONE:	(818) 782-7288
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91402
CAPACITY:	100	CENSUS: 91	DATE:	02/16/2023
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Edgar Cruz		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility is not clean, sanitary and in good repair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced initial complaint visit at the facility today. At 9:40 a.m., the LPA met with the Assistant Administrator Edgar Cruz and explained the reason for the visit. The Administrator was not available during the time of the visit and authorized Edgar Cruz to sign the report.

At 9:50 a.m., the LPA conducted an interview with the Assistant Administrator. At 9:57 a.m., the LPA obtained copies of pertinent documents. At 10:15 a.m., the LPA, along with the Assistant Administrator conducted a physical plant tour. The LPA observed a total of nineteen (19) client rooms. Between 10:16 a.m. and 10:45 a.m., the LPA interviewed fourteen (14) out of ninety-one (91) clients. Between 10:33 a.m. and 10:49 a.m., the LPA interviewed three (3) staff.

Continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230210094042

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SEPULVEDA RESIDENTIAL	FACILITY NUMBER: 197603663
	VISIT DATE: 02/16/2023

NARRATIVE

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Regarding the allegation: Facility is not clean, sanitary and in good repair. It was alleged that the clients rooms are not clean and are not in good repair. During todays visit, the LPA observed a total of nineteen (19) client rooms. Majority of the rooms were observed to be sanitary or in the process of being cleaned by housekeeping. At 10:27 a.m., the LPA observed Staff #1 (S1) cleaning client rooms throughout the second floor. At 10:46 a.m., the LPA observed Staff #2 (S2) cleaning the dining room. During the interview conducted on 02/16/2023, the Assistant Administrator stated that there are three (3) housekeeping staff throughout the week and that each staff are assigned different areas and rooms of the facility to clean. During the time of the visit, there were two (2) housekeeping staff. Additionally, the Assistant Administrator stated that staff conduct weekly room checks and take note if a client room has an issue or needs repairs. At 9:57 a.m., the Assistant Administrator provided copies of receipts of the most recent repairs and maintenance to the LPA. On 02/07/2023, the facility purchased two (2) new toilets for rooms #1 and #46. On 02/08/2023, the facility had L.A. Hydro-Jet & Rooter Service, INC clear the main sewer line. Client interviews conducted on 02/16/2023, stated that staff clean their rooms once to twice a week. The clients stated that the staff sweep, and mob the floors, clean the restrooms, take out the trash and wash the bedsheets. The interviews with clients also noted that staff are helpful, and no concerns were brought up. The information obtained during the investigation did not include sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time.

Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023

LIC9099 (FAS) - (06/04)

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