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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 06/19/2024
Date Signed: 06/19/2024 01:35:47 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
06/10/2024 and conducted by Evaluator Gina Saucedo
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20240610110816
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:
06/19/2024
UNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Mary Jane Reyes, Resident Care DirectorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility does not ensure adequate storage for residents in care
Facility is using residents closet to store facility supplies/items
INVESTIGATION FINDINGS:
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On 06/19/24, at 8:25am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Activites Director, Tabetha Whitehall. Mary Jane Reyes, Resident Care Director arrived at 9:30am. LPA explained the purpose of this visit was to gather additional information and deliver findings for this complaint.

On 06/11/2024, LPA Gina Saucedo initiated the complaint investigation. On 06/11/24, LPA Saucedo asked for the census, staff, and resident roster. On 06/11/24, LPA Saucedo interviewed some staff and residents and conducted a physical tour. On 06/19/24, at 9:35am, LPA conducted another physical tour with Resident Care Director, gathered additional information and conducted more interviews.

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: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
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-20240610110816
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: 06/19/2024
NARRATIVE
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Regarding the allegation: Facility does not ensure adequate storage for residents in care. It is being alleged that because a resident’s room is being used for storing items such as mattresses, wheelchairs, walkers, and old oxygen tanks it is leaving the resident with insufficient space for their personal belongings. Twelve (12) out of twelve (12) residents confirmed that they have adequate space for their personal belongings in their room. Four (4) out of four (4) staff also confirmed that a resident's room is not supposed to be used as storage as this takes up space for the resident's personal belongings. During LPA's physical tour, LPA did not observe any resident rooms to be occupied by storage items such as mattresses, wheelchairs, walkers and/or oxygen tanks. Therefore, based on the LPA's observations, staff, and resident interviews the above allegation(s) is UNSUBSTANTIATED at this time.

Regarding the allegation: Facility is using residents closet to store facility supplies/items. It is being alleged a resident’s closet is being used for storing items such as mattresses, wheelchairs, walkers, and old oxygen tanks. Twelve (12) out of twelve (12) residents confirmed that their closet in their room does not have any facility supplies/items. Four (4) out of four (4) staff also confirmed that a resident's closet is not supposed to store facility supplies/items. During LPA's physical tour, LPA did not observe any resident's closet to have facility supplies/items such as mattresses, wheelchairs, walkers and/or oxygen tanks. 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 allegations, and a copy of this report was given to the Administrator.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina SaucedoTELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
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
06/10/2024 and conducted by Evaluator Gina Saucedo
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20240610110816

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:
06/19/2024
UNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Mary Jane Reyes, Resident Care DirectorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility is in disrepair
INVESTIGATION FINDINGS:
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On 06/19/24, at 8:25am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Activites Director, Tabetha Whitehall. Mary Jane Reyes, Resident Care Director arrived at 9:30am. LPA explained the purpose of this visit was to gather additional information and deliver findings for this complaint.

On 06/11/2024, LPA Gina Saucedo initiated the complaint investigation. On 06/11/24, LPA Saucedo asked for the census, staff, and resident roster. On 06/11/24, LPA Saucedo interviewed some staff and residents and conducted a physical tour. On 06/19/24, at 9:35am, LPA conducted another physical tour with Resident Care Director, gathered additional information and conducted more interviews.

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: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
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-20240610110816
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: 06/19/2024
NARRATIVE
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Regarding the allegation: Facility is in disrepair. It is being alleged that were several water leaks, including one in the ceiling near the dining area, several holes in the memory care hallway, and water damage to several baseboards in the residents’ rooms (specific rooms unknown) and a small hole in the elevator floor, which could pose a tripping hazard. Twelve (12) out of twelve (12) residents confirmed that they have seen the maintenance crew doing repairs throughout the facility, but they do not know the exact repairs being completed. Four (4) out of four (4) staff also confirmed that the maintenance crew are doing repairs throughout the facility including resident rooms, but they do not know the exact repairs being completed. During LPA's physical tour, LPA observed the maintenance crew doing several repairs throughout the facility including resident rooms. Therefore, based on the LPA's observations, staff, and resident interviews the above allegation(s) is SUBSTANTIATED at this time.

An exit interview was conducted, citation(s) were issued for the above allegation(s), Appeal Rights and a copy of this report was given to the Administrator.

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

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20240610110816
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: 06/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/20/2024
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 licensee/admnistrator shall send pictures of repairs being completed by POC due date: 06/20/24.
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Based on the LPA's observations, staff/ resident interviews, the staff did not ensure the residents to have good repair of different areas throughout the facility including rooms and common areas 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: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5