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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 02:10:44 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
07/17/2023 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20230717144517
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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Staff not allowing residents to have visitors.
Staff did not treat resident with dignity and respect.
Staff not providing a safe environment for residents in care.
Facility has bed bugs.
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 07/18/2023 between 10:35 a.m. and 2:30 p.m., LPA Peraldi conducted an interview with the Administrator, ten (10) clients, and five (5) staff. During the initial visit, the LPA also conducted a physical plant tour and obtained copies of pertinent documents. 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 3
Control Number 29-AS-20230717144517
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: 4.) Facility has bed bugs. On 07/17/2023, the Department received a complaint alleging that the facility is infested with bed bugs. During a complaint visit unrelated to this complaint, conducted on 07/06/2023, the LPA cited the facility for failure to keep the facility free insects including bed bugs and the Administrator hired a new pest control company to treat the rooms for bed bugs. Interview conducted with Assistant Administrator on 08/28/2024, revealed that after July 2023, the facility has been free of bed bugs. The Assistant Administrator stated that there currently are no bed bugs, however the facility still receives monthly general pest control. The Assistant Administrator provided a copy of the pest control invoice dated 08/19/2024 to the LPA. During today’s visit, the LPA did not observe bed bugs in clients’ room. 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: 3 of 3
Control Number 29-AS-20230717144517
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: 1.) Staff not allowing residents to have visitors. On 07/17/2023, the Department received a complaint alleging that staff are preventing clients from having visitors. During the visits conducted on 07/18/2023 and 08/28/2024, client interviews revealed that the facility does allow visitation. Staff interviews conducted on 07/18/2023 and 08/28/2024 revealed that they do not limit nor restrict clients from having visitors. During the physical plant tour conducted on 08/28/2024, the LPA observed a sign stating, “Visitors are welcome anytime.” 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.

Regarding the allegation: 2.) Staff did not treat resident with dignity and respect. On 07/17/2023, the Department received a complaint alleging that staff belittle clients. Client interviews revealed that staff are kind and treat clients with respect. Interviews with clients did not voice any concerns regarding staff. Staff interviews revealed that no staff have ever heard staff be disrespectful or rude to the clients. 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.

Regarding the allegation: 3.) Staff not providing a safe environment for residents in care. On 07/17/2023, the Department received a complaint alleging that staff are not providing a safe environment for clients in care as some clients are aggressive towards others. Client interviews revealed that clients feel safe at the facility and had no concerns about their safety. Client interviews revealed that sometimes clients can argue amongst each other however arguments never get physical. Staff interviews revealed that staff are constantly ensuring that the facility is safe for the clients by checking in on clients. The Administrator Assistant stated that the facility keeps the parking lot gate closed for the safety of the clients. 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.

Continued on LIC 9099-C.

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 3