<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608267
Report Date: 10/14/2024
Date Signed: 10/14/2024 02:15:30 PM


Document Has Been Signed on 10/14/2024 02:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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, THEFACILITY NUMBER:
197608267
ADMINISTRATOR:KANDICE VERGARAFACILITY TYPE:
740
ADDRESS:17300 ROSCOE BLVD.TELEPHONE:
(818) 344-2042
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY:175CENSUS: 105DATE:
10/14/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Kandace VergaraTIME COMPLETED:
02:20 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
On 10/14/24, at 12:45pm, Licensing Program Analysts (LPAs) Gina Saucedo and Angelica Segovia arrived at the facility to conduct an unannounced case management visit and was greeted by Administrator, Kandace Vergara.

LPA was advised that a nightstand was put in front of a resident’s bedding while the resident was sleeping on the bed. A picture was taken of this violation.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8 cited and noted on LIC 809D.



Exit interview conducted, a citation(s) was issued, appeal rights and copy of the report was signed and delivered to the Administrator.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina SaucedoTELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2024
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 2


Document Has Been Signed on 10/14/2024 02:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2024
Section Cited
CCR
87608(a)(5)

1
2
3
4
5
6
7
Postural Support-87608(a)(5) (a)Based on the individual's preadmission appraisal, and subsequent changes...the facility shall provide assistance...to a resident who unable to do for himself/herself. Postural supports may be used under the following conditions.(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. This requirement is not met by:
1
2
3
4
5
6
7
Licensee/Administrator shall remove the postural support that deprives the resident of movement limitations and send picture to LPA by POC 10/14/24.
POC Cleared 10/14/24 at time of viist
8
9
10
11
12
13
14
Based on the observation, the licensee/administrator did not ensure a resident was free of postural support that deprived resident of movement limitations at the above facility which poses a potential Health, Safety or Personal Rights risks to person in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Troy AgardTELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina SaucedoTELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2