197608267-6-6-2024-31-AS-TAGD-D6JNVL-20240624104807

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 06/06/2024
Date Signed: 06/06/2024 01:53:04 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
06/03/2024 and conducted by Evaluator Gina Saucedo

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20240603145030

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: 121	DATE:	06/06/2024
		UNANNOUNCED	TIME BEGAN:	09:57 AM
MET WITH:	Mary Jane Reyes		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff failed to protect resident from assault

INVESTIGATION FINDINGS:

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On 06/06/24, at 9:57am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by the Resident Care 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 10:25am, LPA toured the physical plant. During the tour, twelve (12) residents and four (4) 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: 06/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024

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 31-AS-20240603145030

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: 06/06/2024

NARRATIVE

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Regarding the allegation: Staff failed to protect resident from assault. It is being alleged that the staff did not protect the resident from a fight that happened between them and another resident. Twelve (12) out of twelve (12) residents confirmed that they were present when the fight occurred between both residents. Twelve (12) out of (12) residents confirmed that resident #1 (R1) hit resident #2 (R2) and R2 defended themselves. Four (4) out of four (4) staff also confirmed that R1 has a history of yelling, screaming and being aggressive with others. Two (2) out of two (2) staff were present the day the incident occurred and wrote statements of what happened. The administrator confirmed that this type of behavior happened in the past and they have documentation of R1's behavior. During LPA's tour, LPA observed R1 during lunch time in the dining area, start to yell and scream at other residents for no reason while LPA was conducting resident interviews. In addition, LPA obtained the Unusual Incident/Injury Report of the day of the fight and the 911 incident case number. Therefore, based on the LPA's observations and documentation 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 Care Director.

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

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024

LIC9099 (FAS) - (06/04)

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