197608267-12-15-2022-31-AS-EMIR-D8ZMS5-20240911095115

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 12/15/2022
Date Signed: 12/15/2022 01:56:31 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 Michael Cava

COMPLAINT CONTROL NUMBER: 31-AS-20210527105206

FACILITY NAME:	CEDARS ASSISTED LIVING, THE		FACILITY NUMBER:	197608267
ADMINISTRATOR:	ARISTOTLE B. VERGARA		FACILITY TYPE:	740
ADDRESS:	17300 ROSCOE BLVD.		TELEPHONE:	(818) 344-2042
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY:	175	CENSUS: 130	DATE:	12/15/2022
		UNANNOUNCED	TIME BEGAN:	09:01 AM
MET WITH:	Aristotle Vergara, Mary Jane Reyes		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Resident choked on food due to lack of supervision.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to the facility to conclude the investigation regarding the above allegation. It was reported that on or around On 5/21/2021 Resident 1 (R1) choked on their food because they were left eating unsupervised. R1 requires supervision during meals. LPA met with the the Administrator, Aristotle Vergara, and Resident Care Director (RCD), Mary Jane Reyes, and advised them of the allegation. During the course of the visit, interviews with facility staff and residents were made between 9:15am to 12:30pm. Record review was conducted between 12:30pm and 1:00pm. The investigation consisted of the following:

According to both the Administrator and RCD, R1 was non-ambulatory. R1 was verbal, and able to communicate their needs, but required a mechanical diet. R1 was compliant with house rules and medication management. Interviews made with three (3) out of three staff confirmed that they were present, on or around 5/21/2021, when R1 was choking on their food. Staff 1 (S1) stated they were approximately

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022

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-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: 12/15/2022

NARRATIVE

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five meters away when R1 was observed to be choking. S1 called for Staff 2 (S2), who was also present, for assistance and supervision. Both S1 and S2 attempted to perform Heimlich maneuver, while the med tech, Staff 3 (S3), who was also present, called for paramedics. Both S1 and S2 stated R1 was still alive when paramedics arrived. R1 was taken to the hospital for medical attention. Three of the three staff interviewed denied that there was a lack of supervision when R1 was choking. Interviews with ten (10) of ten residents also confirm that there is close supervision in the dining area when meals are served. These residents had no complaints or concerns of any lack of supervision during meals.

Based on the information obtained, there was insufficient evidence to corroborate the allegation of R1 choked on their food due to lack of supervision. Therefore, the allegation is deemed Unsubstantiated at this time.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022

LIC9099 (FAS) - (06/04)

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