197608267-11-21-2024-31-AS-EMIR-DBTQXJ-20241210113333

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 11/21/2024
Date Signed: 11/21/2024 12:33:51 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
06/27/2023 and conducted by Evaluator Mariana Agban

COMPLAINT CONTROL NUMBER: 31-AS-20230627165328

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: 122	DATE:	11/21/2024
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Mary Jane Reyes-Resident Care Director		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Unknown perpetrator physically abused resident in care.
Resident sustained an injury while in care.
Staff handled resident in a rough manner.
Staff used inappropriate language toward resident.
Staff did not ensure that facility was maintained clean and free of pests.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mariana Agban conducted a subsequent complaint investigation to investigate the allegations stated above. LPA met with Resident Care Director and the purpose of the visit was explained.

Allegation: Unknown perpetrator physically abused resident in care.
Allegation: Staff handled resident in a rough manner.

The Complainant alleged that Facility staff had physically mistreated Resident #1 (R1). Alleged mistreatment included but was not limited to slapping R1 on the back of the head, bending R1’s fingers back, and throwing R1 onto R1’s bed as a method of transferring. Interviews with six (6) of 44 staff members and 13 of 134 residents did not identify any witnesses nor did they include any statements or information to corroborate the allegation. The information obtained was insufficient to confirm or deny the allegation and is therefore deemed Unsubstantiated at this time. (Continue on 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

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-20230627165328

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: 11/21/2024

NARRATIVE

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Allegation: Resident sustained an injury while in care.

The Complainant alleged that R1 sustained an injury to R1’s hand. Interviews with three (3) of 44 facility staff corroborate that there was an injury to R1’s hand. Staff #1 (S1) speculated the injury may have been caused when R1 slipped from R1’s wheelchair onto the floor. Interview with Staff#3 (S3) confirmed that R1 slid out of his chair during breakfast time at the dining room. LPA obtained a copy of the Special Incident Report (SIR) indicating the incident. Interviews with 13 of 134 residents did not identify any witnesses nor did they include any statements or information to corroborate the allegation. Therefore, the information obtained was insufficient to confirm or deny the allegation and is therefore deemed Unsubstantiated at this time.

Allegation: Staff used inappropriate language toward resident.

The Complainant alleged that Facility Staff had used language when speaking to R1 that would be considered insulting, offensive, and rude by a reasonable person. The language allegedly included profanity and raised voices. Interviews with 6 out of 44 staff members and 13 out of 134 residents of residents did not identify any witnesses nor did they include any statements or information to corroborate the allegation. The information obtained was insufficient to confirm or deny the allegation and is therefore deemed Unsubstantiated at this time.

Allegation: Staff did not ensure that facility was maintained clean and free of pests.

The Complainant alleged that when R1 was transferred to the memory care unit, R1 was placed in a bedroom that was visibly unclean and in need of repairs. The walls were described as having visible dried spit on them and the floor was patched with duct tape. There was also cockroach activity observed. R1 was moved to another bedroom due to a complaint by R1’s family member. Interviews with Staff 1 (S1) confirmed that they are aware of the pest situation in the facility. The facility has hired a pest control company, to work on the pest situation at the facility. LPA obtains proof of services from the pest control company that confirms the facility is actively working on the situation. Interviews with 13 residents revealed that the facility is successfully working on the pest issue and maintaining the facility clean and free of pets. Based on information obtained the allegation is deemed Unsubstantiated at this time.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

LIC9099 (FAS) - (06/04)

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