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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603663
Report Date: 07/24/2024
Date Signed: 07/24/2024 02:11:34 PM

Document Has Been Signed on 07/24/2024 02:11 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:SEPULVEDA RESIDENTIALFACILITY NUMBER:
197603663
ADMINISTRATOR/
DIRECTOR:
MARK SAMUELFACILITY TYPE:
735
ADDRESS:8025 SEPULVEDATELEPHONE:
(818) 782-7288
CITY:VAN NUYSSTATE: CAZIP CODE:
91402
CAPACITY: 100CENSUS: 86DATE:
07/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:38 AM
MET WITH:Edgardo CruzTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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Licensing Program Analysts (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual inspection visit. The LPA met with Assistant Administrator, Edgardo Cruz and explained the reason for the visit.

The LPA, and 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.

COMMON AREAS: The lobby, TV room, and dining room were observed to be clean and properly furnished The LPA observed the fire extinguishers to be fully charged and last serviced on 06/05/2024. Fire alarm/Carbon monoxide power was observed and was last tested on 02/08/2024 by the Los Angeles Fire Department. The LPA spoke with the facility’s electrician Vardan Zakedosyan who stated that the smoke detector and carbon monoxide alarms are hard wired together. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in the janitor closets and storage room. Passageways were free and clear from obstruction.

KITCHEN: 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 are located in the kitchen area. The walk-in freezer and refrigerator’s temperature were found to be in compliance with regulations. A menu was observed to be posted in the dining room.

Continues on LIC 809C...
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SEPULVEDA RESIDENTIAL
FACILITY NUMBER: 197603663
VISIT DATE: 07/24/2024
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There are two laundry units, one on the first floor and one on the second floor. Medications and first aid kits are located in the locked office. The facility has three medication carts. Indoor temperature was maintained at a comfortable level.

OUTDOOR SPACE: The facility has two outdoor areas for residents to use as smoking areas. The facility has a parking lot area, which has a shaded area for residents' use. There is a gate on the side of the facility for emergency exits. There are no bodies of water on the premises.

RECORDS: Records review began at 1:00 p.m., residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order.

INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

The LPA reviewed the following documents:


- LIC500 Personnel Report
- Residents Roster

Due to time constraints, LPA Urena will return for a continuation inspection visit.

Exit interview conducted, a copy of the report was issued.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC809 (FAS) - (06/04)
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