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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 06/11/2024
Date Signed: 06/11/2024 02:18:06 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
06/04/2024 and conducted by Evaluator Gina Saucedo
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20240604143032
FACILITY NAME:CEDARS ASSISTED LIVING, THEFACILITY NUMBER:
197608267
ADMINISTRATOR:KANDICE VERGARAFACILITY TYPE:
740
ADDRESS:17300 ROSCOE BLVD.TELEPHONE:
(818) 344-2042
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY:175CENSUS: 122DATE:
06/11/2024
UNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Mary Jane Reyes, Resident Care DirectorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff are not providing adequate housekeeping services to resident
Staff are not ensuring that facility is free of odor
INVESTIGATION FINDINGS:
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On 06/11/24, at 8:25am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Medical Technician, Joleen Halog. LPA disclosed the purpose of the visit. Medical Technician called the Resident Care Director and the Resident Care Director arrived at 9:20am. LPA explained the purpose of this visit was to gather additional information and deliver findings for this complaint.

On 06/06/2024, LPA Gina Saucedo initiated the complaint investigation. On 06/06/24, LPA Saucedo asked for the census, staff, and resident roster. On 06/06/24, LPA Saucedo interviewed staff, residents and conducted a physical tour. On 06/11/24, at 10:35am, LPA conducted another physical tour with Resident Care Director and gather additional information.

LIC 9099C-continued.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina SaucedoTELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024
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-20240604143032
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: 06/11/2024
NARRATIVE
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Regarding the allegation: Staff are not providing adequate housekeeping services to resident. It is being alleged that the resident’s bathroom is not properly cleaned as there is urine, hair, and other debris on the floor. Twelve (12) out of twelve (12) residents confirmed that they have cleaning once a week. Four (4) out of four (4) staff also confirmed that they clean the facility on a daily basis. Four (4) out of four (4) staff confirmed that the rooms are cleaned on a weekly basis but if a resident wants additional cleaning, they can request for it. During LPA's physical tour, LPA observed housekeepers cleaning different rooms and caregivers providing resident services. Therefore, based on the LPA's observations, staff, and resident interviews the above allegation(s) is UNSUBSTANTIATED at this time.

Regarding the allegation: Staff are not ensuring that facility is free of odor. It is being alleged that the facility smells like urine. Twelve (12) out of twelve (12) residents confirmed that they have not smelled urine in the facility. Four (4) out of four (4) staff also confirmed that they have not smelled urine in the facility. During LPA's physical tour, LPA did not observe the smell of urine. Therefore, based on the LPA's observations, staff, and resident interviews the above allegation(s) is UNSUBSTANTIATED at this time.

An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Resident Care Director.


SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina SaucedoTELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024
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
06/04/2024 and conducted by Evaluator Gina Saucedo
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20240604143032

FACILITY NAME:CEDARS ASSISTED LIVING, THEFACILITY NUMBER:
197608267
ADMINISTRATOR:KANDICE VERGARAFACILITY TYPE:
740
ADDRESS:17300 ROSCOE BLVD.TELEPHONE:
(818) 344-2042
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY:175CENSUS: 122DATE:
06/11/2024
UNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Mary Jane Reyes, Resident Care DirectorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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9
Staff are not addressing the presence of roaches in the facility
Staff are not ensuring that facility is clean
INVESTIGATION FINDINGS:
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On 06/11/24, at 8:25am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Medical Technician, Joleen Halog. LPA disclosed the purpose of the visit. Medical Technician called the Resident Care Director and the Resident Care Director arrived at 9:20am. LPA explained the purpose of this visit was to gather additional information and deliver findings for this complaint.

On 06/06/2024, LPA Gina Saucedo initiated the complaint investigation. On 06/06/24, LPA Saucedo asked for the census, staff, and resident roster. On 06/06/24, LPA Saucedo interviewed staff, residents and conducted a physical tour. On 06/11/24, at 10:35am, LPA conducted another physical tour with Resident Care Director and gather additional information.

LIC 9099C-continued.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina SaucedoTELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024
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-20240604143032
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: 06/11/2024
NARRATIVE
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Regarding the allegation: Staff are not addressing the presence of roaches in the facility. It is being alleged that the facility is infested with roaches. Twelve (12) out of twelve (12) residents confirmed that they have seen roaches in their room and the common areas of the facility. Four (4) out of four (4) staff also confirmed that they have seen roaches throughout the facility. During LPA's physical tour, LPA observed roaches in several rooms, in resident drawers and in the common areas of the facility. Therefore, based on the LPA's observations, staff, and resident interviews the above allegation(s) is SUBSTANTIATED at this time.

Regarding the allegation: Staff are not ensuring that facility is clean. It is being alleged that the common areas of the facility are dirty. This allegation was recently addressed on 05-31-2024 with control number being 31-AS-20240531103114 and it was SUBSTANTIATED at the time.

An exit interview was conducted, citation(s) were issued for the above allegation(s), and a copy of this report with the appeal rights was given to the Resident Care Director.

SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina SaucedoTELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20240604143032
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: 06/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/12/2024
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:

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The administrator/Licensee must at all times keep a facility free of roaches. The administrator/licensee is to show proof of pest control service/documentation and send to LPA by POC 06/12/2024
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Based on the LPA's observations, staff/ resident interviews, the staff did not ensure the residents to have a clean and sanitary facility including rooms, common areas clean of roaches thus ensuring the facility was clean, which poses an immediate Health, Safety or Personal Rights risks to persons in care.
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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 AgardTELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina SaucedoTELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5