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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603663
Report Date: 05/21/2026
Date Signed: 05/21/2026 01:40:34 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
02/13/2025 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20250213142459
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: 88DATE:
05/21/2026
UNANNOUNCEDTIME BEGAN:
09:32 AM
MET WITH:Edgardo CruzTIME COMPLETED:
12:03 PM
ALLEGATION(S):
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Personal Rights - Questionable Death.
Due to lack of care and/or supervision, resident eloped from the facility.
Due to lack of care and/or supervision, resident sustained unexplained bruising.
Facility staff did not notify resident's responsible party of resident's change in condition.


INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent complaint visit to deliver final findings for the allegation listed above. During today’s visit, LPA Urena met with designated facility staff Edgardo Cruz and explained the reason for the visit.

On 02/13/2025, the Woodland Hills North Regional Office (WHNRO) received a complaint alleging that the Sepulveda Residential facility staff neglected the care of Resident #1 (R1) resulting in R1’s death, which occurred at Providence Holy Cross Medical Center on 02/08/2025.
On 02/14/2025, Licensing Program Analyst (LPA) Zabel Chochian conducted an initial complaint visit to this facility. At approximately 2:00 p.m., the LPA met with the Assistant Administrator Edgardo Cruz and explained the reason for the visit. The LPA spoke with Administrator Mark Samuel on the telephone and reason for the visit was discussed. At 2:15p.m., LPA Chochian and Mr. Cruz conducted a physical plant tour. Between 2:30 p.m. and 3:00 p.m., the LPA reviewed and obtained copies of pertinent documents.
Continues on LIC 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 29-AS-20250213142459
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/21/2026
NARRATIVE
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On 05/19/2025, LPA Urena interviewed the resident’s (R1) family members and the Reporting Party (RP) from approximately 9:00 a.m. to 10:19 a.m. LPA Urena reviewed the following records for R1: Death Certificate, Physician’s Report (LIC 602A), Appraisal/Needs and Service Plan (LIC 628), Centrally Stored Medication and Destruction Record (LIC 622), Medication Administration Record (MAR), Weekly Nursing Assessment Forms, Monthly Doctor’s Office Visits, and Providence Holy Cross Medical Center medical records.

On 06/05/2025, Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent visit to investigate the allegation listed above. The LPA met with the Administrator Mark Samuel and explained the reason for the visit. The LPA Urena interviewed the Administrator and facility staff from approximately 12:21 p.m. to 2:30 p.m. and requested additional documents pertinent to the investigation.
On 04/03/2026, Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent visit to investigate the allegation listed above. The LPA met with the Administrator Mark Samuel and explained the reason for the visit. LPA Urena interviewed staff at approximately 11:10 a.m. and requested additional documents pertinent to the investigation.
Personal Rights (Questionable Death).
On the allegation that R1’s death was due to negligence from facility staff; it is the concern of the reporting party (RP) that when R1 arrived at the hospital on 01/29/2025, “R1 was in bad shape”. R1 had bruising all over the right side of their face and right eye. The RP was informed that R1 was already unconscious when R1 arrived at the hospital and had not woken up. Furthermore, the RP reported that when R1 arrived at the hospital, R1’s blood sugar was very low and possibly the reason for R1’s fall and facial bruise, leading to hospitalization. R1 passed away at the hospital on 02/08/2025. RP believes that the fall incident and death were due to negligence of the facility, because facility staff was not supervising R1 closely enough. Furthermore, the RP reported that R1 had falls in the past, however the RP was unable to provide dates for the falls. The last time the RP visited R1 was around the beginning of December 2024 (prior to the incident when R1 fell and was taken to the hospital 01/29/2025). Family members expressed concern about R1’s cause of death to hospital staff; however, hospital staff informed family that the hospital would not conduct an autopsy and family members were given a telephone number to call for the autopsy to be done. An autopsy was not conducted due to the family’s personal reasons.

Continues on LIC 9099C.3

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

DATE: 05/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20250213142459
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/21/2026
NARRATIVE
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3. LPA Urena conducted interviews with four (4) staff members. One staff member reported that they worked with R1 for about two (2) years and would assist with showers and grooming. Staff stated that R1 was a sweet resident. Staff reported that they saw R1 the day before the hospitalization, during dinner and R1 was observed to be agitated, and aggressive. The morning of 01/29/2025, staff went to look for R1 to assist with the shower, and the staff found R1 in their bedroom facedown. The staff called the Med Tech and the Administrator. The Administrator reported that staff conduct daily rounds checking on residents at the facility between 8:30 a.m. to 9:30 a.m. The morning of 01/29/2025, R1 was observed in their bedroom to be tired, groggy before the incident. The Administrator reported that R1 did not have a history of falls. Administrator reported that staff found R1 in their bedroom floor facedown, and when staff attempted to wake R1, R1 was unresponsive. Staff noticed a bruise on R1’s face near the forehead. The staff called 911. The resident was taken to the hospital, and the Administrator expected R1 to be back to the facility after the hospitalization. Furthermore, the Administrator reported that when Med Tech called the hospital on 02/13/2025 to inquire about R1’s condition and discharge date, they were informed that R1 had passed away on 02/08/2025. Additionally, staff interviews revealed R1’s blood sugar was monitored on a weekly basis and documented on the Weekly Nursing Assessment (WNA) forms and R1 was only taking oral diabetic medication and did not receive any PRN medication.

LPA Urena conducted the following record review of documents pertaining to the investigation.
Record review of the Death Certificate revealed that the immediate cause of death (first disease or condition resulting in death) was listed as Respiratory Failure, and Aspiration Pneumonia, with secondary cause (disease or injury that initiated the events that resulted in death) Hypoglycemic Event, Type 2 Diabetes Mellitus. Review of the Physician’s Report dated 01/14/2025 listed as Primary Diagnosis: Schizophrenia. No other diagnosis was listed in the box labeled Secondary Diagnosis. Review of the Appraisal/Needs and Service Plan (LIC 628) dated 01/06/2025 listed under Physical/Health as R1 being diagnosed with non-insulin dependent Diabetes Mellitus, hypertension, depression, schizophrenia and anemia, and listed R1’s independent functions and living skills “good”. Review of the Centrally Stored Medication and Destruction Record (LIC 622) revealed that R1 was prescribed Metformin to treat diabetes. Additionally, R1 was prescribed medications which cause dizziness and lightheadedness: Benazepril, side effects are listed as dizziness, lightheadedness, especially when rising. Fluoxetine two (2) times a day, side effects listed as dizziness, and Haloperidol, side effects listed as drowsiness, dizziness and blurred vision. Continues on LIC9099C.4
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20250213142459
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/21/2026
NARRATIVE
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4. Review of the Office Visits revealed that R1 was seen by their primary physician monthly. Overall diagnosis was normal at time of the visits, with the following diagnosis being assessed and controlled: Hypertension, Type 2 Diabetes Mellitus without complications, Chronic Kidney Disease (CKD-Stage 2 mild), and iron deficiency, anemia, unspecified. Review of the Medication Administration Record (MAR) revealed that R1 was receiving Metformin HCL 500mg tablets by mouth twice daily (8:00 a.m. and 4:00 p.m.) Record review of the facility’s Weekly Nursing Assessment Forms dated from November 2024 through January 2025, which assess mental status, behavior, falls/ injuries, and appetite, had checkmarks for R1 as “average” on all areas, and noted ‘No’ falls or injuries between 11/05/2024 to 01/27/2025. The records also indicate blood sugar levels ranged between 108-118, with the last reading being 118 on 01/27/2025.

Record review of the medical Admission and Discharge papers obtained from Providence Holy Cross Medical Center revealed that R1 was admitted to the ER on 01/29/2025 with acute altered mental status and bruising on right side of the face. The discharge summary indicated that R1 was treated with antibiotics for acute hypoxemic respiratory failure, likely due to aspiration, and was also treated for hypoglycemic condition. Furthermore, hospital records indicated that initially, a small subdural hematoma was noted but was not deemed the cause of R1’s condition. Despite medical intervention efforts, R1 exhibited a prolonged state of encephalopathy and lack of significant improvement, consequently palliative care was initiated on 02/04/2025. Following the family’s decision made on 02/05/2025, comfort measures were adopted and R1 was pronounced deceased on 02/08/2025.
Based on records review, and interviews, there is not sufficient evidence to support the allegation that R1 died due to the fall and due to negligence of the facility staff. Therefore, the allegation is deemed Unsubstantiated at this time.


Continues on LIC 9099C.5
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20250213142459
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/21/2026
NARRATIVE
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5. Due to lack of care and/or supervision, resident eloped from the facility.
On the allegation that the resident(R1) eloped form the facility, it is alleged by the RP that the resident left the facility without assistance and the next of kin were not informed. RP is unaware if R1 is safe to leave the facility unassisted. LPA urena conducted staff interviews and record reviews pertinent to the investigation. The record review of the Physician’s Report indicates that the resident R1 was able to leave the facility unassisted. Staff interviews revealed that they were aware that R1 had left the facility and were under the impression that R1 had left with a family member, however when they became aware (on the same day of the elopement) that R1 had not returned to the facility, facility staff contacted the family members to ask about R1. Facility staff, upon learning that R1 was not with family members, contacted law enforcement and filed a missing person report. Interview of family members revealed that the facility staff indeed called to ask about R1’s whereabouts; however, family members reported that they were the ones who told facility staff to contact law enforcement and file a missing person report.
Based on information obtained through interviews and record review, the information revealed that the resident (R1) was able to leave the facility unassisted. Therefore, the allegation that the resident eloped due to the facility’s staff lack of supervision, is deemed Unsubstantiated at this time.
Due to lack of care and/or supervision, resident sustained unexplained bruising.
On the allegation that the resident (R1) sustained unexplained bruises, it is alleged by the RP that in the past there had been incidences when R1 sustained bruises; however, no information was provided by facility staff to the family as to how R1 got the bruises, other than stating R1 fell. LPA Urena conducted record review pertaining to the investigation. Record review of the facility’s Weekly Nursing Assessment Forms dated from November 2024 through January 2025, which assesses falls/ injuries, had checkmarks for R1 as average on all areas, and noted ‘No’ falls or injuries between 11/05/2024 to 01/27/2025. Furthermore, R1 was prescribed medications which cause dizziness and lightheadedness: Benazepril, side effects are listed as dizziness, lightheadedness, especially when rising. Fluoxetine two (2) times a day, side effects listed as dizziness, and Haloperidol, side effects listed as drowsiness, dizziness and blurred vision, which could have contributed to the falls, and unintended bruising. Staff interviews revealed that R1 may have sustained minor bruises, however the facility staff could not say that they were due to falls and did not recall bruising that would be of concern.
Although the allegation may have happened or is valid, based on the interviews, and record review there is not sufficient evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time. Continues on LIC 9099C.6
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20250213142459
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/21/2026
NARRATIVE
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6. Facility staff did not notify resident's responsible party of resident's change in condition.
On the allegation that the residents’ responsible party were not informed of resident’s change in condition, the RP alleges that the R1’s responsible party was never informed that R1’s medications had changed. To investigate the allegation, LPA Urena conducted record review pertinent to the investigation. Record review revealed that R1 was self-responsible, R1 did not have a Power of Attorney (POA) or a court appointed Conservator. Interviews with facility staff indicate that although they communicated with R1’s next of kin about R1’s condition when asked, R1 ultimately was responsible for themselves.

Based on the information obtained through record review and interviews, facility staff did communicate with resident’s next of kin, however R1 was their own responsible party. Therefore, the allegation is deemed Unsubstantiated at this time.

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

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

DATE: 05/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6