197608267-6-3-2024-31-AS-TAGD-D6JNFH-20240624102535

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 06/03/2024
Date Signed: 06/03/2024 03:14:56 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/31/2024 and conducted by Evaluator Gina Saucedo

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20240531103114

FACILITY NAME:	CEDARS ASSISTED LIVING, THE		FACILITY NUMBER:	197608267
ADMINISTRATOR:	KANDICE VERGARA		FACILITY TYPE:	740
ADDRESS:	17300 ROSCOE BLVD.		TELEPHONE:	(818) 344-2042
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY:	175	CENSUS: 120	DATE:	06/03/2024
		UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Mary Jane Reyes		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff did not meet resident’s hygiene needs
Staff discarded resident’s clothing without consent of resident’s authorized representatives

INVESTIGATION FINDINGS:

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On 06/03/24, at 10:25am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Resident Director, Mary Jane Reyes. LPA disclosed the purpose of the visit. LPA explained the purpose of this visit was to gather information, conduct staff and resident interviews and deliver findings for this complaint.

The investigation consisted of the following: LPA Saucedo asked for the census, requested the staff and resident roster. At 11:05am, LPA toured the physical plant. During the tour, twelve (12) residents and five (5) staff were interviewed.

9099C-continued

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2024

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 5

Control Number 31-AS-20240531103114

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: CEDARS ASSISTED LIVING, THE	FACILITY NUMBER: 197608267
	VISIT DATE: 06/03/2024

NARRATIVE

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Regarding the allegation: Staff did not meet resident’s hygiene needs. It is being alleged that the resident’s hair is unkept and dirty. Twelve (12) out of twelve (12) residents confirmed that their hygiene needs are met at the above facility and if they need anything extra they can request it from any of the staff. Five (5) out of five (5) staff also confirmed that the resident's hygiene needs are met based on their level of care; some residents need more help than others depending on the level of care that the individual has. During LPA's tour, LPA did not observe any resident needing hygiene care. Therefore, based on the LPA's observations, staff and resident’s interviews the above allegation(s) is unsubstantiated at this time.

Regarding the allegation: Staff discarded resident’s clothing without consent of resident’s authorized representatives. It is being alleged that the resident’s clothing has been thrown away. Twelve (12) out of twelve (12) residents confirmed that they know the policy of personal property and valuables, theft and loss. Five (5) out of five (5) staff also confirmed they know they are to report immediate loss or damage to a resident's property/valuable to management staff. During LPA's record review, all residents have a Client/Resident Property Log in their file. Therefore, based on the LPA's observations and record review, staff and resident’s interviews the above allegation(s) is unsubstantiated at this time.

An exit interview was conducted, and a copy of this report was given to the Resident Director.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/31/2024 and conducted by Evaluator Gina Saucedo

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20240531103114

FACILITY NAME:	CEDARS ASSISTED LIVING, THE		FACILITY NUMBER:	197608267
ADMINISTRATOR:	KANDICE VERGARA		FACILITY TYPE:	740
ADDRESS:	17300 ROSCOE BLVD.		TELEPHONE:	(818) 344-2042
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY:	175	CENSUS: 120	DATE:	06/03/2024
		UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Mary Jane Reyes		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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9

Staff did not ensure to keep facility free of mold
Staff did not ensure to keep facility clean

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2024

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

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 31-AS-20240531103114

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: CEDARS ASSISTED LIVING, THE	FACILITY NUMBER: 197608267
	VISIT DATE: 06/03/2024

NARRATIVE

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Regarding the allegation: Staff did not ensure to keep facility free of mold. It is being alleged that the above facility has mold. Twelve (12) out of twelve (12) residents did say that their room is cleaned on a weekly basis and they see different staff cleaning. Five (5) out of five (5) staff say that the rooms get cleaned weekly. During LPA's physical tour, LPA toured different rooms and was able to observe that some bathrooms were not clean and free of mold. Therefore, based on the LPA's observations, the above allegation(s) is SUBSTANTIATED at this time.

Regarding the allegation: Staff did not ensure to keep facility clean. It is being alleged that the above facility is filthy. Twelve (12) out of twelve (12) residents did say that the facility is cleaned on a daily basis and see different staff cleaning different areas. Five (5) out of five (5) staff say the facility gets cleaned everyday depending on the workers they have on a particular day. During LPA's physical tour, LPA toured different rooms and was able to observe that some rooms were not clean and in disrepair. Therefore, based on the LPA's observations, the above allegation(s) above is SUBSTANTIATED at this time.

An exit interview was conducted, citation(s) given, appeal rights, and a copy of this report was given to the Resident Director.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 31-AS-20240531103114

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: CEDARS ASSISTED LIVING, THE	FACILITY NUMBER: 197608267
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/03/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/04/2024 Section Cited CCR 87303(a)(1)	1 2 3 4 5 6 7	87303 Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times...(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The administrator/Licensee must at all times keep a facility free of mold. At the time of visit there was a maintenance crew of three (3) individuals repairing/cleaning the bathroom and light fixture of resident #1(R1). POC CLEARED at time of visit-06/03/24
	8 9 10 11 12 13 14	Based on the LPA's observations, the staff did not ensure the residents to have a clean and sanitary bathroom free of mold, surface areas of bathroom need repair and light fixture needs a cover which poses an immediate Health, Safety or Personal Rights risks to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 5