197603663-9-19-2024-29-AS-KHEN-D9EV2Z-20240924160359

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603663
Report Date: 09/19/2024
Date Signed: 09/19/2024 11:11:14 AM

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-20230717162300

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: 90	DATE:	09/19/2024
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Mark Samuel, Administrator		TIME COMPLETED:	11:26 AM

ALLEGATION(S):

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Staff did not prevent residents from using illegal drugs.
Staff did not prevent resident from hitting other residents.
Resident jumped out the window sustaining injuries due to staff neglect.
Staff are making inappropriate comments towards residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit to this facility. At 10:40 a.m., the LPA met with the Administrator, Mark Samuel and explained the reason for the visit.
During the initial visit conducted on 07/18/2023 between 10:35 a.m. and 02:50 p.m., LPA Peraldi conducted an interview with the Administrator, ten (10) clients and five (5) staff. LPA Peraldi also conducted a physical plant tour and obtained copies of pertinent documents. On 07/18/2023, a referral was made to Community Care Licensing Division's (CCLD) Investigation Branch (IB) and was accepted as an assignment to conduct interviews and obtain documents and assigned to Investigator Juan Lozano. On 08/01/2023, Investigator Lozano conducted interviews with three (3) clients, including Client #1 (C1). On 08/17/2023, Investigator Lozano conducted a telephonic interview with Assistant Administrator, Edgar Cruz. Additionally, on 09/17/2024, LPA Peraldi conducted a telephonic interview with the Administrator.
Continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230717162300

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: 09/19/2024

NARRATIVE

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The following was then determined:
Regarding the allegation: 1.) Staff did not prevent residents from using illegal drugs. On 07/17/2023, the Department received a complaint alleging illegal drug usage on the premise of the facility by various clients including, Client #1 (C1). Information gathered during the course of the investigation and interviews conducted revealed that clients, including C1, have never seen any person use illegal drugs in the facility. C1 denied usage of illegal drugs on the premise of the facility. Interviews conducted with staff denied the allegation and stated that they have no knowledge of anyone at the facility having engaged in illegal drug use. Administrator also denied knowledge of illegal drug use at the facility. Additionally, Investigator Lozano did not observe narcotics or illegal drugs while at the facility. 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 prevent resident from hitting other residents. On 07/17/2023, the Department received a complaint alleging Client #1 (C1) hitting several other clients. Client interviews conducted on 07/18/2023, revealed that clients are kind to one another and have not observed physical altercation among other clients. Staff interviews revealed that C1 can talk loudly but has not had physical altercations with other 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.) Resident jumped out the window sustaining injuries due to staff neglect. On 07/17/2023, the Department received a complaint alleging Client #2 (C2) jumping out of the window and sustaining unknown injuries. Per record review, the facility sent the Department an unusual incident/ injury report regarding C2 falling in the parking lot on 07/05/2023. The unusual incident/ injury report stated that C2 was then transferred to the hospital. Interview conducted with the Assistant Administrator and Administrator revealed that after hospitalization, C2 was admitted to a skilled nursing facility (SNF) for rehabilitation as C2 had hip fracture from the fall. The Administrator stated that from the SNF, C2 was admitted to another facility and did not return to this facility. Client interviews conducted on 07/18/2023, revealed clients did not observe or witness C2 falling out the window. Continued on LIC 9099-C.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230717162300

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: 09/19/2024

NARRATIVE

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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: 4.) Staff are making inappropriate comments towards residents. On 07/17/2023, the Department received a complaint alleging staff belittling clients. Client interviews conducted on 07/18/2023, 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.

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

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC9099 (FAS) - (06/04)

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