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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 02/10/2022
Date Signed: 02/10/2022 03:20:32 PM

Unsubstantiated


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
05/27/2021 and conducted by Evaluator Alexander Pitz
COMPLAINT CONTROL NUMBER: 31-AS-20210527105206
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: 103DATE:
02/10/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Aris VergaraTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident sustained an injury due to an unwitnessed fall
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Pitz conducted an unannounced visit on this day in response to the above allegations. During this investigation LPA conducted a visit to the facility and interviewed one relevant witness (W1) and four staff members on 6/1/21 at 09:00 a.m.; interviewed W1 telephonically and reviewed relevant facility records and medical records for Resident 1 (R1) on 9/21/21; attempted to interview additional witnesses on 9/22/21; and conducted a visit to the facility to review client records and interview facility administrator on 2/10/21 at 10:15 a.m.
Allegation #1, that “Resident sustained an injury due to an unwitnessed fall,” has been unsubstantiated based on the records reviewed. On 9/21/21 LPA reviewed the Valley Presbyterian Hospital intake records for R1 and observed that R1 was admitted for a fall on 4/3/21. Those records indicate that a CT scan was performed of the spine and skull; no acute fractures/ injuries were noted and no emergency care treatment was provided at the hospital. R1 was discharged the same day with a prescription for Tylenol.
Report reviewed, signed and delivered. Exit interview conducted, no deficiency cited.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
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 6
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
05/27/2021 and conducted by Evaluator Alexander Pitz
COMPLAINT CONTROL NUMBER: 31-AS-20210527105206

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: 103DATE:
02/10/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Aris VergaraTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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9
Resident developed a UTI while in care
Resident wandered from the facility due to lack of supervision
Facility failed to report incidences
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Pitz conducted an unannounced visit on this day in response to the above allegations.


During this investigation LPA conducted a visit to the facility and interviewed one relevant witness (W1) and four staff members on 6/1/21 at 09:00 a.m.; interviewed W1 telephonically and reviewed relevant facility records and medical records for Resident 1 (R1) on 9/21/21; attempted to interview additional witnesses on 9/22/21; and conducted a visit to the facility to review client records and interview facility administrator on 2/10/21 at 10:15 a.m.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
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 6
Control Number 31-AS-20210527105206
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
VISIT DATE: 02/10/2022
NARRATIVE
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Allegation #1, that “resident developed a UTI while in care,” has been substantiated based on the records reviewed and interviews conducted. On 9/21/21 LPA reviewed the Valley Presbyterian Hospital intake records for R1 and observed that R1 was admitted for a Urinary Tract Infection (UTI) on 4/3/21. At the time of LPA’s visit on 6/1/21, the most recent assessment done of R1 was from 1/11/19, and it indicates that R1 was incontinent and required full assistance with toileting, dressing and grooming.

Allegation #2, that “resident wandered from the facility due to lack of supervision” has been substantiated based on the records reviewed and interviews conducted. On 5/11/17 the facility submitted an incident report for R1, indicating that R1 was "on monitoring throughout the day and was caught waiting at the bus stop...wanted to visit friends..does not know where they live.” A review of facility records shows that the most recent assessments conducted prior to this incident were on 1/3/17, when his level of care was assessed to have increased from “lvl 2” to “lvl 3” and he was recommended for memory care, and 12/8/16 when a Mental Status Questionnaire indicated that R1 was experiencing “severe brain dysfunction.”

Allegation #3, that “Facility failed to report incidences,” has been substantiated based on the interviews conducted and records reviewed. On 6/1/21 LPA asked the Wellness Director and Resident Care Director if there were any other recent reportable incidents for R1 that came to mind, aside from the 5/21/21 choking incident, and both failed to mention or provide any documentation for the fact that R1 was taken to the hospital on 4/3/21 for a fall and UTI. On 9/21/21 LPA reviewed the 4/3/21 hospital records for R1 as well as the Woodland Hills South Regional Office’s log of incident reports from the facility, and did not observe any record of this incident being reported to Community Care Licensing.

Report reviewed, signed and delivered. Exit interview conducted, deficiencies cited on 9099D page.

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 31-AS-20210527105206
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: 02/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/14/2022
Section Cited
CCR
87464(f)(1)
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(f) Basic services shall at a minimum include:

(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c


This requirement is not met as evidenced by:
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Administrator will conduct a review of all resident appraisals to ensure that they are current and accurate. Staff training will be provided on the topics of preventing resident AWOLs.
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Based on the records reviewed, the facility did not ensure that R1 was provided with adequate care and suprvision to prevent R1 from leaving the facility without any supervision which poses an immediate risk to the residents in care.
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Type B
02/21/2022
Section Cited
CCR
87464(f)(4)
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(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports.
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Administrator will provide proof of staff training being provided on the topic of incontinence care and preventing UTIs.
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This requirement is not met as evidenced by:

Based on records reviewed, the facility did not ensure that adequate personal assistance and care was provided to prevent the development of a UTI which poses a potential risk to residents 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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 31-AS-20210527105206
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: 02/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/21/2022
Section Cited
CCR
87211(a)(1)(D)
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(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.

This requirement is not met as evidenced by:
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Administrator, Wellness Director, and Resident Care Director will all sign a statement of understanding and intent to abide by the cited regulation.
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Based on the records reviewed and interviews conducted, the facility did not report that R1 was hospitalized on 4/3/21 for a Fall and UTI which poses a potential risk to residents 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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6