197603663-6-22-2022-29-AS-EPEI-CFMPUH-20220622113733

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603663
Report Date: 06/22/2022
Date Signed: 06/22/2022 11:38:19 AM

Document Has Been Signed on 06/22/2022 11:38 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

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: 94	DATE:	06/22/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:21 AM
MET WITH:	Mark Samuel, Administrator		TIME COMPLETED:	11:45 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 10:21 a.m., the LPA was greeted and screened by staff. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Mark Samuel and discussed the reason for the visit. At 10:33 a.m., the LPA, along with Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. KITCHEN: At 10:34 a.m., the LPA observed the kitchen/dining area. Knives are stored in the locked kitchen. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Emergency food and water located in the locked kitchen area. At 10:35 a.m., the LPA observed staff handing out food to the residents. BEDROOMS: The LPA observed multiple resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Passageways were free and clear from obstruction. Inside temperature was maintained at a comfortable level. RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition. At 10:38 a.m., the LPA observed resident restrooms hot water to be measured between 122.7 and 126.0-degree Fahrenheit. At 10:39 a.m., the Administrator observed the hot water temperature and requested staff to set the hot water no more than 120-degree Fahrenheit. At 10:45 a.m., staff adjusted the hot water temperature to read between 105 and 120 degrees Fahrenheit. Continued on LIC 809-C.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022

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

LIC809 (FAS) - (06/04)

Page: 1 of 3

Document Has Been Signed on 06/22/2022 11:38 AM - It Cannot Be Edited

Created By: Emily Peraldi On 06/22/2022 at 10:52 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SEPULVEDA RESIDENTIAL	FACILITY NUMBER: 197603663
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as hot water temperature in residents’ restrooms measured between 122.7 and 126.0-degree Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/22/2022
	Plan of Correction
1 2 3 4	Staff adjusted hot water heater temperature during facility visit. Administrator stated that they will maintain hot water temperature between 105 and 120 degrees Fahrenheit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Kristin Heffernan

LICENSING EVALUATOR NAME:

Emily Peraldi

LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SEPULVEDA RESIDENTIAL	FACILITY NUMBER: 197603663
	VISIT DATE: 06/22/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

COMMON AREAS: The LPA observed common areas to be relatively clean and properly furnished. Signs are posted throughout facility to promote hand-washing, cough/sneeze etiquette, and physical distancing. At 10:35 a.m., the LPA observed the fire extinguisher to be fully charged and last serviced on 06/02/2022. Fire alarm/emergency power was observed and was last tested on 01/31/2022. At 10:40 a.m., the LPA observed staff cleaning residents’ rooms and hallways on both the first and second floor.

OUTDOOR SPACE: The LPA observed the back lot, which has a covered outdoor area for resident use. There is an open gate on the side of the facility.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate.

At 10:26 a.m., the LPA conducted Infection Control mitigation module with Administrator.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted with staff, Edgar Cruz. The Administrator authorized Edgar Cruz to sign the report. Report issued and a copy of the report and appeal rights was provided via email.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3