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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603663
Report Date: 08/28/2024
Date Signed: 08/28/2024 02:03:13 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
07/21/2023 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20230721081244
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: 84DATE:
08/28/2024
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Mark Samuel, AdministratorTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Facility staff sleep during their shift.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit to this facility. At 9:35 a.m., the LPA met with the Assistant Administrator, Edgar Cruz and explained the reason for the visit. The LPA also met with the Administrator during the time of the visit.

During the initial visit conducted on 07/26/2023 between 9:40 a.m. and 4:00 p.m., LPA Peraldi and LPA Zabel Chochian conducted an interview with the Assistant Administrator, seven (7) clients, and four (4) staff. During the initial visit, LPA Chochian also conducted a physical plant tour. During today’s visit, between 9:50 a.m. and 10:27 a.m., the LPA conducted interview with six (6) residents, and three (3) staff. The LPA also conducted a physical plant tour and obtained copies of pertinent documents during the time of the visit.

Continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
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-20230721081244
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: 08/28/2024
NARRATIVE
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Regarding the allegation: Facility staff sleep during their shift. On 07/21/2023, the Department received a complaint alleging that night shift staff sleep during their shift. Client interviews conducted on 07/26/2023 and 08/28/2024 revealed that clients have not observed staff including night staff sleep during their shift. Client interviews did not reveal any concerns regarding staff. Staff interviews denied that staff sleep during their shift. The information obtained during the investigation did not include evidence sufficient 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 deemed Unsubstantiated at this time.

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

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2