197603663-9-19-2024-29-AS-KHEN-D9EUAR-20240924152509

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603663
Report Date: 09/19/2024
Date Signed: 09/19/2024 11:09:58 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
06/19/2023 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20230619090726

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:	11:25 AM

ALLEGATION(S):

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Resident was injured by staff.
Staff assaulted resident.

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 06/20/2023 between 10:18 a.m. and 11:30 a.m., LPA Peraldi conducted an interview with the Assistant Administrator, conducted a physical plant tour and obtained copies of pertinent documents. During a subsequent visit conducted on 07/18/2023 between 10:35 a.m. and 2:50 p.m., the LPA conducted interview with ten (10) clients and five (5) staff. The LPA also conducted a physical plant tour and obtained copies of pertinent documents during the time of the subsequent visit.

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-20230619090726

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 allegations: 1.) Resident was injured by staff. 2.) Staff assaulted resident. On 06/19/2023, the Department received a complaint alleging that an unknown male staff held down Client #1 (C1) while Staff #1 (S1) punched C1’s arm causing C1’s arm to bruise. Information provided from the complainant revealed that C1 was observed with bruises on C1’s arm, however the complainant was not able to attest the origins of C1’s bruises. Interview with C1 revealed inconsistent statements regarding staff and which staff hit C1. C1 stated that C1 loves living at the facility and that the Administrator and Assistant Administrator treat C1 well. However, C1 stated that housekeeping staff and kitchen staff are aggressive towards C1, and that Staff #2 (S2) hit C1 on C1’s arm. C1 did not provide dates of the incident or further information. Per record review, S2 is not an employee at the facility nor is there evidence that S2 was employed in the past. Interview conducted with S1 revealed that S1 denied hitting C1. During staff interviews, staff denied observing other staff hit or mistreat clients. Interviews conducted with clients revealed that facility staff are nice and reported having no concerns regarding staff. The information obtained during the investigation did not include evidence sufficient to corroborate the allegations, as interview with C1 was inconsistent and no concerns regarding staff were reported during clients’ interviews. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are 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: 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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