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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 04/02/2025
Date Signed: 04/02/2025 11:46:26 AM

Substantiated


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
04/01/2025 and conducted by Evaluator Gina Saucedo
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20250401144855
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: 103DATE:
04/02/2025
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Kandace Vergara, AdministratorTIME COMPLETED:
11:55 AM
ALLEGATION(S):
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Staff does not ensure facility floor is kept in good repair for residents
INVESTIGATION FINDINGS:
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On 04/02/25, at 8:40am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Medication Technian, Jolene Halog. LPA explained the purpose of this visit was to deliver findings for this complaint.

On 04/02/25, LPA Saucedo asked for the census, staff, and resident rosters. On 04/02/25, LPA Saucedo conducted a physical tour and interviewed staff and residents.

LIC 9099C-continued



Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
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 3
Control Number 31-AS-20250401144855
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: 04/02/2025
NARRATIVE
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Regarding the allegation: Staff does not ensure facility floor is kept in good repair for residents. It is being alleged that resident #1's (R1's) is in disrepair. During LPA's physical tour, LPA did observe R1's floor in disrepair with the wood laminate flooring lifting. LPA's physical tour consisted of fourteen (14) random rooms being toured and did not observe any other floors being in disrepair and/or lifting. LPA did interview R1 and R1 confirmed that their room floor was observed to be in disrepair several weeks ago and was told they would move rooms but never did. R1 will be temporarily moved to another room while repairs are being conducted. LPA interviewed two (2) staff that confirmed that R1's room floor is in disrepair and will be temporarily moved from their room while repairs are being conducted. Therefore, based on the LPA's observations, resident and staff interviews, the above allegation(s) above is SUBSTANTIATED at this time.

Exit interview was conducted, a citation(s) was issued for the above allegation(s), the appeals rights and a copy of this report was given to the Administrator.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20250401144855
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: 04/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/30/2025
Section Cited
CCR
87303(a)(1)
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87303 (a)(1)-Maintenance:(a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall...for the safety and well-being of residents, employees and visitors (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:
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The licensee/administrator shall send a picture/repair paperwork to the LPA of repairs conducted.

POC due date: 04/30/25.
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Based on the LPA observation and interviews the licensee/administrator did not comply with the section cited above in one area/room that needs to be safe and repaired which poses a Potential 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.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3