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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 03/30/2022
Date Signed: 03/30/2022 04:09:45 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/25/2022 and conducted by Evaluator Joscelyn Martinez
COMPLAINT CONTROL NUMBER: 31-AS-20220325133246
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: 108DATE:
03/30/2022
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Aristotle Vergara TIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Staff did not properly clean resident's room
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joscelyn Martinez conducted an unannounced compliant investigation in regards to the allegations mentioned above . At 9:45 a.m. LPA Martinez arrived at the facility and was greeted by front desk staff. LPA later met with Administrator Aristotle Vergara. The purpose of this visit was explained.
To investigate these allegations, LPA Martinez interviewed ten (10) our of 108 residents. LPA Martinez also conducted interviews with four (4) staff members. Relevent documents were obtained.

Allegation: Staff did not properly clean resident's room. Interviews conducted between 10:30 a.m and 3:00 p.m determined that housekeeping did not properly clean Resident’s 1 bedroom (R1). Two staff member also confirmed that R1’s bedroom was not being properly cleaned. Based on these interviews and documentation, this allegation is Substantiated at this time.

Deficiency cited refer to 9099D. Report signed and delivered. Appeal rights issued.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/25/2022 and conducted by Evaluator Joscelyn Martinez
COMPLAINT CONTROL NUMBER: 31-AS-20220325133246

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: 108DATE:
03/30/2022
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Aristotle Vergara TIME COMPLETED:
04:20 PM
ALLEGATION(S):
1
2
3
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5
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7
8
9
Resident was injured by another resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joscelyn Martinez conducted an unannounced compliant investigation in regards to the allegations mentioned above . At 9:45 a.m. LPA Martinez arrived at the facility and was greeted by front desk staff. LPA later met with Administrator Aristotle Vergara. The purpose of this visit was explained.
To investigate these allegations, LPA Martinez interviewed ten (10) our of 108 residents. LPA Martinez also conducted interviews with four (4) staff members. Relevent documents were obtained.


Allegation: Resident was injured by another resident in care. Interviews of staff and residents were conducted between 10:30 a.m. and 3:00 p.m. At this time there is not sufficient evidence to support the allegation that a resident was injured by another resident in care. This allegation is Unsubstantiated at this time.

Exit interview conducted. Report signed and delivered.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20220325133246
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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, THE
FACILITY NUMBER: 197608267
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/06/2022
Section Cited
CCR
87303(a)
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87303(a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times

This requirement is not met as evidenced by:

Based on interviews, the Administrator did not comply with this section cited above in
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POC was already cleared during the time of the visit. Administrator will train staff on how to properly dispose of the trash cans in resident’s room. Administrator will email proof of training to LPA Martinez no later than 04/06/22.
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ensuring resident's room were properly clean which poses a potential health, safety or personal rights risk 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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4