197608267-9-6-2023-31-AS-RORN-D9UT72-20241008142759

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 09/06/2023
Date Signed: 09/06/2023 04:42:44 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
08/30/2023 and conducted by Evaluator Evelin Rios

COMPLAINT CONTROL NUMBER: 31-AS-20230830161734

FACILITY NAME:	CEDARS ASSISTED LIVING, THE		FACILITY NUMBER:	197608267
ADMINISTRATOR:	KANDICE VERGARA		FACILITY TYPE:	740
ADDRESS:	17300 ROSCOE BLVD.		TELEPHONE:	(818) 344-2042
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY:	175; 175	CENSUS: 143	DATE:	09/06/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Mary Jane Reyes		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Resident was pushed by staff.

INVESTIGATION FINDINGS:

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On 09/06/2023 Licensing Program Analysts (LPAs) Evelin Rios and Mariana Agban conducted an unannounced complaint visit for the above allegation. LPAs arrived at 10:00 a.m. and were greeted by Resident Care Director, Mary Jane Reyes. LPA explained the reason for the visit. An entrance interview was conducted with Mary Jane Reyes.

From 10:00 a.m. to 12:00 p.m. LPA Rios interviewed three (3) staff familiar with the incident the complaint is about. From 12:00 p.m. to 1:30 p.m. LPA conducted a physical plant tour of the facility and along with the tour LPA interviewed R1 and five (5) other residents in the dining area where the incident in question took place. From approximately 1:30 p.m. - 2:20 p.m. LPA reviewed and obtained documents relevant to the investigation.

Allegation: Resident was pushed by staff.
In regards to the allegation, it was reported that staff #1 (S1) pushed resident #1 (R1). (Cont. on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

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-20230830161734

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CEDARS ASSISTED LIVING, THE	FACILITY NUMBER: 197608267
	VISIT DATE: 09/06/2023

NARRATIVE

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To investigate the allegation LPA Rios interviewed staff and residents present during the time the incident in question took place. Staff interviews reveal R1 was yelling and S1 stood between R1 and another resident #2 (R2). Interview with R1 and S1 corroborate, R1 had asked S1 to fill R1's pitcher with ice and when S1 did not provide ice R1 became upset and began to yell and curse. R2 then moved from their location in the dining hall and confronted R1. S1 then stood between R1 and R2. Both parties corroborate that S1 was facing R1 during the incident. LPA interviews with five (5) out of six (6) residents present during the incident corroborate they either heard or witnessed R1 yelling. During R1's interview R1, affirmed, S1 pushed R1 with both hands. When Interviewed S1, denied the allegation. According to S1, an empty plastic pitcher R1 was holding made contact with S1's head. Due to no witness, no visible injuries, and no history of similar allegations against staff in question there was not enough evidence to prove the alleged violation did or did not occur therefore the allegation is deemed Unsubstantiated at this time.

No deficiencies cited. Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

LIC9099 (FAS) - (06/04)

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