197603663-7-26-2023-29-AS-KHEN-D5QTGY-20240529144355

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603663
Report Date: 07/26/2023
Date Signed: 07/26/2023 03:52:03 PM

Unsubstantiated

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
07/24/2023 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20230724132755

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: 93	DATE:	07/26/2023
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Edgar Cruz, Assistant Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is withholding resident's personal belongings.
Facility staff did not administer prescribed medication to resident.
Facility did not safeguard resident's personal items.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analysts (LPAs) Emily Peraldi and Zabel Chochian conducted an unannounced initial complaint visit to this facility. At 9:40 a.m., the LPAs met with the Assistant Administrator and explained the reason for the visit. At 10:52 a.m., LPA Peraldi spoke with the Administrator and the Administrator was not available during the time of the visit.

At 9:56 a.m., LPA Peraldi conducted an interview with the Assistant Administrator. At 10:00 a.m., LPA Peraldi reviewed records and obtained copies of pertinent documents. Between 10:23 a.m. and 11:15 a.m., the LPAs conducted interviews with seven (7) clients and four (4) staff. At 10:25 a.m., LPA Chochian, along with the Assistant Administrator, conducted a physical plant tour. At 12:00 p.m., the LPAs conducted a review of medication and medication documentation with Assistant Administrator for five (5) clients and observed that all medications were properly documented and dispensed as prescribed.
Continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

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 3

Control Number 29-AS-20230724132755

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: 07/26/2023

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: Facility is withholding resident's personal belongings. The complainant is alleging that after Client #1 (C1) moved out of the facility back in May 2023, that C1 returned to the facility the next day and tried to pick up personal belongings but that the facility staff would not allow C1 from doing so. During an interview with the Assistant Administrator on 07/26/2023, it was revealed that C1 moved out of the facility on 05/31/2023 and C1’s personal belongings were moved out of the facility with the help of C1’s social worker. The Assistant Administrator stated that C1 does have larger items still at the facility, but neither C1 nor C1’s social worker has communicated with the facility regarding C1’s larger items. Interviews with staff and observation revealed that C1’s larger items are still at the facility. Staff stated that C1’s clothing and important items such as documentation and medications were taken by C1 on 05/31/2023. Additionally, during records review a signed document by C1 dated 05/31/2023 was observed stating that C1 has moved out and removed all their belongings, including money and medications from the facility. Interview with C1 conducted on 07/26/2023, did not provide additional information to support the above allegation. C1 could not confirm that an arrangement was made with facility staff to pick up remaining personal items. The information obtained during the investigation did not include sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time.

Regarding the allegation: Facility staff did not administer prescribed medication to resident. The complainant alleged that the facility staff refused to administer medications to C1. During an interview with the Assistant Administrator on 07/26/2023, it was revealed that staff would always assisted C1 with self-administration of medication. The Assistant Administrator stated that C1 would always take their medications and in rare occasions would refuse. Interview with C1 conducted on 07/26/2023, C1 did not provide additional information to support the above allegation. During the interview, C1 could not provide the name of the medication that was refused to C1. During the time of the visit, the LPAs conducted a record review of C1’s file. During the review of records, medication and medication documentation, the LPAs did not observe discrepancies or missing medications. The information obtained during the investigation did not include sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20230724132755

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: 07/26/2023

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: Facility did not safeguard resident's personal items. The complainant alleged that the facility staff did not safeguard C1’s personal items by giving them away to other clients at the facility. During an interview with the Assistant Administrator on 07/26/2023, it was revealed that C1 moved out of the facility on 05/31/2023 and C1’s personal belongings were moved out of the facility with the help of C1’s social worker. The Assistant Administrator stated that C1 did not leave behind clothing or hygiene items and stated that the only items left behind were larger items like a couch and street signs. The Assistant Administrator denied that facility staff gave away C1’s personal items. Interviews conducted with C1’s previous roommate confirmed that C1’s personal items were moved out and were not given to other clients. Additionally, seven (7) out seven (7) random client interviews did not report concern regarding the safeguard of their personal items and belongings. Interview with C1 conducted on 07/26/2023, did not provide additional information to support the above allegation. The information obtained during the investigation did not include sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time.

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

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3