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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603663
Report Date: 07/06/2023
Date Signed: 07/06/2023 03:42:08 PM

Document Has Been Signed on 07/06/2023 03:42 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:SEPULVEDA RESIDENTIALFACILITY NUMBER:
197603663
ADMINISTRATOR:MARK SAMUELFACILITY TYPE:
735
ADDRESS:8025 SEPULVEDATELEPHONE:
(818) 782-7288
CITY:VAN NUYSSTATE: CAZIP CODE:
91402
CAPACITY: 100CENSUS: 94DATE:
07/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Mark Samuel, AdministratorTIME COMPLETED:
04:00 PM
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Licensing Program Analysts (LPAs) Emily Peraldi and Brian Balisi arrived at the facility unannounced to conduct a required annual visit. At 9:40 a.m., the LPAs met the Administrator and explained the reason for it visit.
At 10:00 a.m., the LPA, along with the Assistant Administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations.

KITCHEN: The LPAs observed the kitchen/dining area. Knives are stored inside the locked kitchen. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Emergency food and water located in the locked kitchen area.

BEDROOMS: LPA Peraldi observed multiple client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Passageways were free and clear from obstruction.

RESTROOMS: LPA Peraldi observed the restrooms to be relatively sanitary. Between 10:08 a.m., and 10:41 a.m., hot water measured between 106.4 and 110.7-degree Fahrenheit. LPA Peraldi observed the restroom’s ventilation fans inoperable on both floors. The ventilation fans are being addressed on a separate report, complaint 29-AS-20230628155604. The Licensee explained that the restroom ventilation fans are currently being repaired.

COMMON AREAS: The LPA observed common area to be relatively clean and properly furnished. The LPA observed the fire extinguishers to be fully charged and last serviced on 06/06/2023. Fire alarm/emergency power was observed and was last tested on 01/2023. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in the janitor closets and storage. Continued on LIC-809-C.
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.

LIC809 (FAS) - (06/04)
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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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SEPULVEDA RESIDENTIAL
FACILITY NUMBER: 197603663
VISIT DATE: 07/06/2023
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There are laundry units on both floors. At 10:29 a.m., LPA Peraldi observed staff cleaning clients’ rooms and hallways on both the first and second floor. Medications and first aid kits are located in the locked office. Inside temperature was maintained at a comfortable level.

OUTDOOR SPACE: At 10:43 a.m., LPA Peraldi observed the back lot, which has a covered outdoor area for resident use. There is a gate on the side of the facility for emergency exits. There are no bodies of water on the premises.
Between 10:08 a.m. and 10:37 a.m., LPA Peraldi conducted interviews with ten (10) out of ninety-four (94) clients. At 11:00 a.m., LPA Balisi conducted interviews with five (5) staff.

RECORD REVIEWS: At 10:00 a.m., LPA Balisi conducted a file review for nine (9) clients and all staff regularly scheduled and observed the following: Staff have current first aid and training documentation showing required training completed. Client records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All files were in order.

Between 11:17 a.m. and 11:40 a.m., LPA Peraldi conducted a review of medication and medication documentation with Assistant Administrator for eight (8) clients and observed that all medications were properly documented and assisted with as prescribed.

No deficiencies cited in regard to the annual. Exit interview conducted. A copy of the report was issued.
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
LIC809 (FAS) - (06/04)
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