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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608267
Report Date: 02/25/2025
Date Signed: 02/25/2025 01:27:17 PM

Document Has Been Signed on 02/25/2025 01:27 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/
DIRECTOR:		KANDICE VERGARAFACILITY TYPE:
740
ADDRESS:17300 ROSCOE BLVD.TELEPHONE:
(818) 344-2042
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 175TOTAL ENROLLED CHILDREN: 0CENSUS: 104DATE:
02/25/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Mary Jane Reyes, Resident Care DirectorTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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On 2/25/25 at 09:35 AM, Licensing Program Analyst (LPA) Gina Saucedo conducted an unannounced visit to the facility to conduct a Case Management visit. LPA was greeted by Resident Care Director, Mary Jane Reyes and Administrator Alexander Solorio (Pasadena Administrator). LPA stated the reason for their visit. The purpose for the visit was to follow up on a self-reported incident (02-20-25) which alleged that Resident #1 (R1) was hit by a staff member on 02/19/25.

LPA requested census, staff, and resident rosters. LPA reviewed R1's file obtained from Pasadena Villa Senior Living (198603286). LPA conducted a physical tour of the facility and interviewed staff and residents. LPA interviewed R1 regarding the incident and R1 revealed that their blanket was missing, they went retrieved it and went back into their room. When they went back into their room, staff #1 (S1) followed them, pulled the blanket from R1, pulled their hair and hit R1 in the chest area. S1 and S2 were interviewed by management staff and S1 and S2 had inconsistent stories. S1 is currently on administrative leave and S2 was removed from the Memory Care unit where R1 is currently residing. LPA interviewed S3 and S4 and both staff reported that when they arrived on shift that morning, R1 had reported the incident to them. S4 reported the incident to their management staff. The management staff interviewed R1 on the day of the incident, reported the incident via SOC341 to Community Care Licensing Department, Ombudsman, APS Police Department and R1's representative. The management staff also interviewed another staff-S5 who reported seeing S1 hit another resident recently which was reported on another SOC341. Resident #2 (R2) was interviewed but they did not confirm or deny any incident occurring. Let it be noted, R2 is in the Memory Care unit. Furthermore, management staff provided a mandated reporter training on 02/21/25 for all staff to report all incidents. LPA obtained a copy of the training.

Based on LPA's record review staff and resident interviews, a citation will be issued on a 809-D

Exit interview conducted, a citation(s) was issued, appeal rights and copy of the report was signed and delivered to the Resident Care Director.

Troy AgardTELEPHONE: (818) 596-4334
Gina SaucedoTELEPHONE: (818) 304-3057
DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/25/2025 01:27 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: 02/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/11/2025
Section Cited
CCR
87468.1(a)(3)

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87468.1(a)(3) Personal Rights of Residents in All Facilities.(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature..This requirement is not met as evidenced by:
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The licensee/admnistrator shall immediately place the staff on administrative leave or/and discharge them from their work duties.

POC Cleared 02/25/25
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Based on the LPA's Interviews the licensee/administrator did not ensure that staff provide an environment free of punishment/intimidation/abuse of residents in care which poses an potential Health, Safety or Personal Rights risks to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Troy AgardTELEPHONE: (818) 596-4334
Gina SaucedoTELEPHONE: (818) 304-3057

DATE: 02/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2025

LIC809 (FAS) - (06/04)
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