197603663-7-6-2023-29-AS-DPEA-CUWTJK-20230821144627

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603663
Report Date: 07/06/2023
Date Signed: 07/06/2023 03:46:02 PM

Substantiated

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
06/28/2023 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20230628155604

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: 94	DATE:	07/06/2023
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Mark Samuel, Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff did not keep the facility free of cockroaches
Facility is in disrepair (bathroom ventilation)
Staff did not keep the facility free from mold

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Emily Peraldi and Brian Balisi conducted an unannounced initial complaint visit to this facility. At 9:40 a.m., the LPAs met with the Administrator and explained the reason for the visit.

During today’s visit, at 10:01 a.m., the LPAs conducted an interview with the Administrator. At 10:05 a.m., LPA Peraldi conducted an interview and physical plant tour with the Assistant Administrator. Between 10:08 a.m. and 10:37 a.m., LPA Peraldi conducted interviews with ten (10) out of ninety-four (94) clients. Additionally, at 11:00 a.m., the LPAs reviewed records and obtained copies of pertinent documents.

Continued on LIC 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

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-20230628155604

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: 07/06/2023

NARRATIVE

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Regarding the allegations: “Staff did not keep the facility free of cockroaches, “Facility is in disrepair (bathroom ventilation)” and “Staff did not keep the facility free from mold.” The Department received information from a credible witness who indicated during a recent visit on 06/27/2023 the following items were observed: Evidence of cockroach infestations in kitchen and room #29, the bathroom in room #6 was observed to have mold, and multiple restroom ventilation fans were inoperable. During today’s visit, Administrator explained that all maintenance and pest issues are being addressed. The Administrator continued to state that common areas, the kitchen, and rooms were sprayed and treated for cockroaches. The Administrator provided the LPAs copies of the invoices and receipts of Zaver Pest Control dated 06/28/2023 and 07/05/2023. During today’s visit, the LPAs did not observe any evidence of cockroaches. The Assistant Administrator stated that maintenance is working on fixing or replacing the client’s restroom ventilation fans. At 10:11 a.m., LPA Peraldi observed most restroom ventilation fans under repair. Interview with the administrator revealed that mold in Room #6 has been treated on 06/28/2023. At 10:08 a.m., LPA Peraldi did not observe any evidence of mold in room #6. All issues are in process of being addressed and the Administrator will provide proof of repairs to the LPA. Based on the information provided by a credible witness and interviews, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated at this time.

Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, and California Health and Safety Code the following deficiency were cited (refer to LIC 9099-D). Failure to correct the deficiency may result in civil penalty.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230628155604

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/06/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/06/2023 Section Cited CCR 80087(a)(1)	1 2 3 4 5 6 7	80087 (a)(1) Buildings and Grounds (a) The facility shall be clean...at all times for the safety and well-being of clients...(1) The licensee shall take measures to keep the facility free... other insects.This requirement is not met as evidenced by:	1 2 3 4 5 6 7	On 06/28/23, the Administrator hired a new pest control company to treat the rooms. The Administrator replaced the beds in Rooms #6 and #7 and is continuing to treat for both bed bugs and cockroaches. The Administrator sent the LPA receipts and invoices. Plan of correction met.
	8 9 10 11 12 13 14	Based on interviews, the licensee failed to comply with the section cited above as a credible witness observed bed bugs in Rooms #6 and cockroaches which poses a potential health and personal rights risk to persons in care.	8 9 10 11 12 13 14
Type B 07/21/2023 Section Cited CCR 80087(a)	1 2 3 4 5 6 7	80087 (a) Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator stated that the restroom ventilation fans are under repair and that the mold has been treated and painted over in Room #6. The Administrator agreed to submit proof of the repairs being completed by 07/21/2023 to CCL.
	8 9 10 11 12 13 14	Based on interviews, the licensee failed to comply with the section cited above as restroom ventilation fans were in operable and as mold was observed by a credible witness in Room #6 which poses a potential health and personal rights risk to persons in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

LIC9099 (FAS) - (06/04)

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