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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608267
Report Date: 06/19/2020
Date Signed: 06/19/2020 01:05:31 PM

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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:CEDARS ASSISTED LIVING, THEFACILITY NUMBER:
197608267
ADMINISTRATOR:ARISTOTLE B. VERGARAFACILITY TYPE:
740
ADDRESS:17300 ROSCOE BLVD.TELEPHONE:
(818) 344-2042
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY:175CENSUS: 114DATE:
06/19/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Aris VergaraTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Desaree Perera initiated Case Management - Incident visit. The purpose of this visit is to follow up on a special incident report (SIR) submitted to the department on 06/17/2020. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, todays visit was conducted telephonically with administrator Aris Vergara.

It was reported that on 05/29/2020, Resident #1 (R1) requested Staff #1 (S1) to perform an inappropriate sexual act and S1 obliged to R1's request. Per report submitted to CCLD, the incident was witnessed by S2. During today's telephonic visit, LPA conducted an interview with the administrator and requested documents pertaining to the incident to be submitted to LPA. Per administrator, the incident was not reported to management until 06/16/2020.

Prior to issuing final licensing report, it has been determined that further investigation is needed at this time.


Exit Interview Conducted via telephone and report was emailed for signature.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-343
LICENSING EVALUATOR NAME: Desaree PereraTELEPHONE: (747) 230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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