<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603663
Report Date: 07/06/2023
Date Signed: 07/06/2023 03:47:44 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/20/2023 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20230620163841
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
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Mark Samuel, AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not ensure resident's room was free of bed bugs
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Emily Peraldi and Brian Balisi conducted an unannounced subsequent complaint visit to this facility. At 9:40 a.m., the LPAs met with the Administrator and explained the reason for the visit.

During the initial visit conducted on 06/27/2023 between 12:28 p.m. and 1:10 p.m., LPA Peraldi conducted an interview with the Administrator, conducted a brief physical plant tour and obtained copies of pertinent documents. During today’s visit, at 10:01 a.m., the LPAs conducted an interview with the Administrator. At 10:05 a.m., LPA Peraldi conducted an interview and physical plant tour with the Assistant Administrator. Between 10:08 a.m. and 10:37 a.m., LPA Peraldi conducted interviews with ten (10) out of ninety-four (94) clients. Additionally, at 11:00 a.m., the LPAs reviewed records and obtained copies of pertinent documents.

Continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 29-AS-20230620163841
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Regarding the allegation: Staff did not ensure resident's room was free of bed bugs. On 06/20/2023, the Department received a complaint alleging that Room #7 has bed bugs. Interviews conducted and records reviewed revealed bedbugs were observed in Room #6 and #7. On 07/06/2023, the Administrator explained that he hired a new pest company, Zaver Pest Control to treat the bed bugs immediately. The Administrator explained that the previous pest company was at the facility on 06/20/2023 and did not report any issues. The Administrator explained that the clients also received new beds and clean bedsheets. The Administrator explained that the rooms are still being sprayed and treated. The Administrator provided the LPAs copies of the invoices and receipts of Zaver Pest Control dated 06/28/2023 and 07/05/2023. Based on the information provided by a credible witness, and interviews, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated at this time.

Although the allegation was Substantiated, the failure to keep the facility free insects was cited on a separate report from an inspection conducted on 07/06/2023.

Exit interview conducted. A copy of the report was provided.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 2