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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 02:13:38 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-20230717090907
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 did not prevent a resident from injuring another resident in care.
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 2
Control Number 29-AS-20230717090907
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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Department received a complaint alleging that staff did prevent Client #1 (C1) from getting injured by Client #2 (C2); as C2 pushed C1 causing C1 to fall and sustain an injury to the chest. During the initial visit, staff interviews revealed that C1 and C2 are roommates and friends. Staff stated that C1 and C2 have not had issues in the past. Interview conducted with C1 during the initial visit revealed that C1 and C2 are on good terms now and that it was the first and only time C2 pushed C1. C1 did not know why C2 pushed C1. C1 stated that there are no issues with C2 and that C2 paid for C1’s hospital bill. Interview conducted on 08/28/2024 with Assistant Administrator revealed that C2 moved out of the facility in November 2023 and that C1 has a new roommate. During today’s visit, the LPA conducted an interview with C1, and C1 did not voice any issues or concerns. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation, as interviews revealed that C1 and C2 did not have a history of fighting or arguing. 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