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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603663
Report Date: 07/15/2025
Date Signed: 07/15/2025 09:20:50 PM

Document Has Been Signed on 07/15/2025 09:20 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: 82DATE:
07/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Mark SamuelTIME VISIT/
INSPECTION COMPLETED:
02:36 PM
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Licensing Program Analyst (LPA) Sandra Urena arrived unannounced at the facility to conduct a required annual inspection visit. The LPA met with the Administrator Mark Samuel and Assistant Administrator (AD), Edgardo Cruz and explained the reason for the visit. At the time of the visit, the facility is going through building renovations. The residents are temporarily being relocated to vacant rooms to allow for their room’s renovations. The renovations include new windows, entrance doors, stairs, floors, painting, new furniture, new AC units, and making adaptations for functionality and esthetics in each of the bedrooms.

The LPA, the Administrator and the AD 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 05/20/2025. Fire alarm/Carbon monoxide power was observed and was last tested on 01/29/2025 by the Los Angeles Fire Department. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in closets and storage room. Passageways were free and clear from obstruction. There are three laundry units, one is located on the first floor and second is located on the second floor. Indoor temperature was maintained at a comfortable level.
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 pantry room. 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...
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Sandra Urena
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2025
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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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)
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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: 07/15/2025
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BEDROOMS: The LPA was able to observe rooms which were recently renovated. The rooms were observed to have new AC units, flooring, and renovated bathrooms (which now have a shower area, and pedestal sinks). The residents’ bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

OUTDOOR SPACE: The facility has outdoor areas for residents to use as smoking areas. One area on the first floor and one area on the second floor. There is a gate on the side of the facility for emergency exits. There are no bodies of water on the premises.

RECORDS: Residents' and staff files are kept in the office area. Due to time constraints, LPA Urena will return for a Continuation Inspection visit.

MEDICATIONS: Medications are locked in the room adjacent the front office. The facility has three medication carts. Due to time constraints, LPA Urena will return for a Continuation Inspection visit.

The LPA reviewed the following documents:


- LIC 500 -Personnel Report
- LIC 9020-Residents Roster
- Certificate of Liability
- Emergency Drills

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

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

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Sandra Urena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
LIC809 (FAS) - (06/04)
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