197608267-10-4-2021-31-AS-JMAZ-C7H44S-20211004184650

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608267
Report Date: 10/04/2021
Date Signed: 10/04/2021 06:48:33 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
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: 108	DATE:	10/04/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Aristotle Vergara		TIME COMPLETED:	07:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Joscelyn Martinez, Gary Tan, and Yelena Avestisyan conducted an unannounced 1-Year Required Inspection at the facility today and met with Administrator Aris Vergara and explained the purpose of the visit. The facility consists of two( 2) memory care units (Willow and Evergreen) and an assisted living unit. There are currently twenty eight (28) residents residing in Willow Memory Care, twenty (20) residents residing in Evergreen Memory Care and sixty (60) residents residing in assisted living At 9:00 am, LPAs conducted record reviews of randomly selected staff and residents. At 2:40 PM, LPAs conducted a physical plant tour with the administrator to ensure that there is no health and safety hazard and facility is in compliance. The following were observed: Memory Care Units: (Willow and Evergreen Memory Care) The following were observed. There were no required COVID sings in the hallways nor walls. There were PPE stations throughout the memory care unit, there was no covered trash bin to discard the PPE upon exit. At 2:55 PM upon entrance in room 109 and 107 LPAs smelled a strong foul odor. In room 108 there was no running water in the bathroom sink, and resident's room did not have the require furnishing as well as the exit door was locked from the inside also, room 107 was observed to be locked from the inside. At 3:05 PM LPAs also tested the pull cord in room 108 and staff did not response. LPA's pulled the pull cord in room 238 and no staff responded. LPAs observed the second floor dining room flooring and tables in disrepair. (Continue on LIC 809-C)

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/04/2021

NARRATIVE

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ASSISTED LIVING: at 3:25 pm, a random selection of five assisted living units on level 1 and level 2 wereinspected. .LPAs observed that the door in room 105 was locked from the inside in that has bedridden fire clearance. Room 142 has a camera, empty portable oxygen tank, lamp cover was broken, exit door leading to the patio is unlocked, fire alarm is not working and the flooring is in disrepair. Pull cord was tested at 3:30 pm and no staff responded. Room 136, blinds were in disrepair, bathroom sink is clogged and no smoke alarm was installed or removed. Room 210 has no furniture and no night stand and the carpet was dirty. Room 221 blinds were broken and the resident is using full bed rails with without doctor's order. Room 242 resident is bed bound but the room in only cleared for non-ambulatory only. Random residents bathroom water temperature were checked and measured at a range of 118 degrees Fahrenheit to 164.1 degrees Fahrenheit. All grab bars were observed to be in good repair.

COMMON AREAS: The fire extinguishers are located all over the facility and last inspected on 09/20/21 . The facility is equipped with fire sprinkles. Dining room not currently being used.

RESIDENT RECORDS: at 9:00 am, a random selection of 11 resident files were reviewed. Files reviewed were complete with, but not limited to signed admission agreements, medical assessments and current appraisals. 5 out of 5 residents with dementia did not have a updated Physician reports. Eleven out of Eleven residents' file did not have an updated Appraisal and Needs and Service Plan.

STAFF RECORDS: At 11:00 am, a random selection of 6 staff files were reviewed. Staff files reviewed had health screenings with TB results and medication training requirements. One out of six staff files did not have a Health and Screening on file. Four of six staff files does not have a current First Aid Certificate.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22. A copy of the report and appeal rights provided.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021

LIC809 (FAS) - (06/04)

Page: 2 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/04/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)(2)

All facilities shall maintain a fire clearance. Prior to accepting persons over 60 years of age none ambulatory and/or bedridden the licensee shall notify the licensing agency and obtain an appropriate fire clearance. This requirement is not met as evidenced by: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on Based on observation and interview the licensee did not comply with the cited section by retaining 6 out of 7 bedridden residents in rooms that were do not have bedridden fire clearance which poses an immediate health, safety and personal rights risk to persons in care. (Room 106,136, 208, 221,242, 240, )
	POC Due Date: 10/06/2021
	Plan of Correction
1 2 3 4	This is a zero tolerance violation therefore civil penalty in the amount of $500 has been issued. Civil penalties in the amount of $100 dollars per day will accrue until POC is received.

Type A

Section Cited

CCR

87608(a)(5)(B)

Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations made the licensee did not comply with the section cited above by utilizing full bedrails for 5 residents who are on hospice however licensee does not have hospice care plan which indicates the need for the rails which poses an immediate health, safety and personal rights risk to persons in care..
	POC Due Date: 10/06/2021
	Plan of Correction
1 2 3 4	Licensee/administrator will conduct a tour of the resident rooms. Identify the residents who are utilizing full rails and half rails. Licensee/administrator will submit copy of the hospice care plans for those residents who are on hospice to indicate the need for the rails.

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 Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021

LIC809 (FAS) - (06/04)

Page: 3 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/04/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87633(b)

A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: This requirement is not met as evidenced by: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not maintaining a hospice care plan for 13 out of 13 residents who are currently on hospice which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/11/2021
	Plan of Correction
1 2 3 4	Licensee/Administrator will contact the hospice agencies and obtain current/updated hospice care plans for all residents. The hospice care plans will have to include the frequency of the visits. Copies of the care plans will be submitted as POC.

Type B

Section Cited

CCR

87705(c)(5)(A)

Licensees who accept & retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment, & a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA record review, the licensee did not comply with the section cited by not obtaining an Annual Medical assessment and not completing annual re-appraisals for 5 out of 5 residents diagnosed with dementia. This poses a potential health and safety risk to the residents in care.
	POC Due Date: 10/11/2021
	Plan of Correction
1 2 3 4	POC: Licensee/Administrator will review files for all residents., Identify the residents whose physician report and the appraisal needs and services/reappraisals are older than 1 year, Contact the residents physicians and obtain a current and complete Medical Assessment for all residents. Contact the residents responsible party to update that appraisal needs and services plan. Licensee/Administrator will submit list of the identified residents by 10/7/2021 and submit a self-certification once all medical assessment and the appraisal needs and services plans have been updated. The certification will need to list the names of the identified residents and the dates updated. All records and Medical Assessments will need to be updated on or before 10/22/2021.

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 Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021

LIC809 (FAS) - (06/04)

Page: 4 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/04/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(3)

Postural Supports. A written order from a physician indicating the need for postural support shall be maintained in the resident’s record. The licensing agency is authorized to require additional documentation if needed. This requirement is not met as evidenced by: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on Records reviewed, observations made the licensee did not comply with the section cited above by not obtaining an order for postural support for 10 residents which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/11/2021
	Plan of Correction
1 2 3 4	Licensee/administrator will conduct a tour of the resident rooms. Identify the residents who are utilizing full rails and half rails. Licensee/administrator will contact the residents physicians and obtain a doctors order for the postural supports. Copies will need to be submitted to the LPA as POC.

Type B

Section Cited

CCR

87303(a)

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations made during physical plan tour the licensee did not comply with the section cited above by not ensuring that the facility was maintained, sanitary, odor free and in good repair at all times.
	POC Due Date: 10/11/2021
	Plan of Correction
1 2 3 4	Licensee/Administrator will conducted a tour of all residents rooms, bathrooms and other areas of the facility 2. Licensee/administrator will create a maintenance log for each room and identify the areas in need of repair by 10/8/2021. Licensee/Administrator will need to complete all repairs as identified on the maintenance log by October 29,2021. Copy of the maintenance log will need to be submitted to LPA by 10/8/2021. Licensee/administrator will notify the Department once repairs are completed.

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 Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021

LIC809 (FAS) - (06/04)

Page: 5 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/04/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87203

Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations made the licensee did not comply with the section cited above by locking designated exit doors with a key inside the residents rooms which poses and immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/06/2021
	Plan of Correction
1 2 3 4	Licensee administrator will submit a written statement indicating how this deficiency will be corrected. Licensee will also submit photos of the corrections. This is a zero tolerance violation and civil penalties have been assessed for $500.00. . Additional civil penalties in the amount of $100.00 will continue to accrue daily until complete POC has been received. This is a zero tolerance violation therefore civil penalty in the amount of $500 has been issued. Civil penalties in the amount of $100 dollars per day will accrue until POC is received.

Type A

Section Cited

CCR

87203

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations made the licensee did not comply with the section cited above by not ensuring smoke detectors are properly working throughout the facility which poses and immediate health, safety or personal rights risk to persons in care..
	POC Due Date: 10/06/2021
	Plan of Correction
1 2 3 4	Administrator agreed to fix or put or replace the smoke detectors all over the facility and will submit proof of correction or or before the POC date. This is a zero tolerance violation therefore civil penalty in the amount of $500 has been issued. Civil penalties in the amount of $100 dollars per day will accrue until POC is received.

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 Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021

LIC809 (FAS) - (06/04)

Page: 6 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/04/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)(e)

Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation during physical plant tour, the licensee did not comply with the section cited above by not ensuring water temperature was properly regulated to a maximum of 120 degrees which poses an immediate health, safety and personal rights risk to persons in care
	POC Due Date: 10/06/2021
	Plan of Correction
1 2 3 4	Administrator agreed to adjust the water temperature immediately and will continue to monitor for the next seven (5) days by submitting water temperature log for random residents' bathroom AM/PM and submit this to CCL.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021

LIC809 (FAS) - (06/04)

Page: 7 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/04/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87618(b)(3)(b)

In addition to Section 87611(b), the licensee shall be responsible for the following: (3)Ensuring that the use of oxygen equipment meets the following requirements: (B)"No Smoking-Oxygen in Use" signs shall be posted in the appropriate areas. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations made during physical plan inspections the licensee did not comply with the section cited above by not ensuring "No Smoking-Oxygen in Use" signs are posted near resident rooms.
	POC Due Date: 10/11/2021
	Plan of Correction
1 2 3 4	Administrator has agreed to place appropriate signage in appropriate rooms. Administrator will identify all residents who use oxygen. Once completed licensee will be submit photo to CCL for proof of completion.

Type B

Section Cited

CCR

87307(a)(3)(B)

Living accommodations and grounds shall be related to the facility's function. The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (B)Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation made the licensee did not comply with the section cited above by not ensuring that all residents have the required furnishings on their rooms, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/11/2021
	Plan of Correction
1 2 3 4	Licensee has agreed to inspect all of resident’s room, identify required furnishing that are missing. Licensee will then provide required furniture to residents and submit copies of receipt for POC as will as the list of the rooms identified.

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 Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021

LIC809 (FAS) - (06/04)

Page: 8 of 8