197603663-7-22-2026-29-AS-KLOZ-DWHVYZ-20260731165157

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603663
Report Date: 07/22/2026
Date Signed: 07/22/2026 01:50:11 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
06/09/2026 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20260609170359

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: 86	DATE:	07/22/2026
		UNANNOUNCED	TIME BEGAN:	12:17 PM
MET WITH:	Edgardo Cruz		TIME COMPLETED:	01:55 PM

ALLEGATION(S):

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Staff choked resident.
Staff handled resident in a rough manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced subsequent visit to deliver the findings for the allegations listed above. The LPA met with Edgardo Cruz, facility representative and explained the reason for the visit.

On 06/09/2026, the CCLD Department received a complaint, and on 06/17/2026, LPA Urena conducted an initial visit. LPA Urena interviewed staff and residents and requested records pertinent to the investigation.

Conbtinues on LIC 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2026

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-20260609170359

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: 07/22/2026

NARRATIVE

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Staff choked resident.
On the allegation that staff choked the resident; it is alleged that a facility staff grabbed the resident by the neck, after the resident (R1) asked for the third time for a food item, and allegedly the facility staff (S1) choked the resident. To investigate the allegation, LPA Urena conducted residents’ and staff interviews. LPA Urena interviewed S1 on the phone, due to S1’s day off. S1 denied choking or hurting R1. Furthermore, S1 reported that R1 was the one who became aggressive towards S1, when R1 was asked to wait. Out of courtesy for the other residents waiting in line, S1 asked R1 to step to the side of the line and told R1 that once the other residents were served, S1 would provide the third request to R1. This request by S1 appeared to upset R1, and R1 proceeded to act in a menacing way towards S1, at which time, S1 moved and backed away from R1 into the kitchen area. S1 reported that they were also afraid that R1 would injure other residents. S1 stated that they kept talking to R1 and begged R1 to try to calm down and attempted to de-escalate the situation. R1 was telling insults to S1. Eventually, R1 calmed down and became compliant. Per S1, R1 apologized after R1 calmed down and said to S1, "I am sorry" and walked away. The interview with the Staff (S2) revealed that S2 was not present when the incident happened, which was in the nighttime. S2 reported that S1 denied the allegation of touching R1. Furthermore, S2 stated, " I can assure you that if S1 had placed their hands on R1, all the residents present would have reported it to us right away". And there were many residents waiting in line. The Reporting Party’s (RP) interview revealed that they had a telephone conversation with R1, and this is the time when R1 shared the altercation between R1 and S1. The RP reported that R1 reported being choked by staff after asking for a third serving of food, and RP stated that at some point in their conversation R1 stated, "It was my fault, I should not have done that". RP stated that R1 reported the incident to the Administrator. R1 reported that they did not get bruises or scratches due to the choking or being handled in a rough manner. R1’s interview revealed that R1 asked for a third serving of food when suddenly S1 pushed R1 back with their hand, by placing the hand in the front of the neck area. Furthermore, the R1 reported that S1 did not grab the neck area, did not leave any marks or bruises. When the LPA asked R1 if S1 had ever touched R1 in an aggressive manner, R1 said, "No" LPA then asked R1 if anyone had witnessed the attack given that there was a line of residents behind R1 waiting for their snack, R1 stated that they don’t think the residents behind R1 saw what happened.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2026

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20260609170359

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: 07/22/2026

NARRATIVE

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Residents’ interviews revealed that they do not remember witnessing the incident. Administrator’s interview revealed that they spoke with the resident and spoke with the staff (S1), S1 denied grabbing R1 by the neck.
Although the allegation may have happened or is valid, based on the interviews, there is not sufficient evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time.

Staff handled resident in a rough manner.
On the allegation that staff handled resident in a rough manner; it is alleged that facility staff (S1) grabbed the resident (R1) by the neck, causing the resident to experience pain in their throat and neck area following an incident. To investigate the allegation the LPA conducted resident’s and staff interviews. S1 denied grabbing R1 by the throat or in a rough manner or causing pain in any manner. R1’s interview revealed that they felt uncomfortable when S1 pushed R1 back with the palm of their hand and placing it in the neck area of R1. R1 reported no injuries, scratches or marks left on the neck. Residents’ interviews revealed that they did not witness the incident. Administrator’s interview revealed that they were informed of the incident, and S1 denied the allegation of handling the resident in a rough manner.

Although the allegation may have happened or is valid, based on the interviews, there is not sufficient evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time.

No citations were issued. Exit interview was conducted. A copy of the report was issued.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2026

LIC9099 (FAS) - (06/04)

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