197608267-1-29-2025-31-AS-TAGD-DEJNSP-20250307094324

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 01/29/2025
Date Signed: 01/29/2025 01:18:32 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
01/02/2025 and conducted by Evaluator Gina Saucedo

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20250102160228

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	CENSUS: 113	DATE:	01/29/2025
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Mary Jane Reyes, Resident Care Director		TIME COMPLETED:	01:25 PM

ALLEGATION(S):

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Staff did not prevent residents from engaging in an altercation resulting in a fracture to resident in care

INVESTIGATION FINDINGS:

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On 01/29/25, at 9:35am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Resident Care Director, Mary Jane Reyes. LPA explained the purpose of this visit was to gather additional information, interview additional staff and residents and deliver findings for this complaint.

On 01/02/25, this complaint was referred to the Investigations Branch (IB) but was returned to the Regional Office (RO) on 01/06/25 for investigation, due to it being the first incident of an altercation between the residents and there was no history of aggression based on both resident’s care plan. The staff also broke up the altercation and sought medical attention. On 01/03/25, LPA Ngo-Castaneda conducted an initial complaint and asked for the census, staff, and resident rosters. On 01/29/25, LPA Saucedo interviewed staff, residents and conducted a physical tour.

LIC 9099C-continued

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025

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-20250102160228

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 01/29/2025

NARRATIVE

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Regarding the allegation: Staff did not prevent residents from engaging in an altercation resulting in a fracture to resident in care. It is being alleged that resident #1 (R1) got in an altercation with resident #2 (R2) and was punched in their face which resulted in a non-displaced fracture at the level of the base of the left mandibular incisor. An Unusual Incident/Injury Report was sent to Community Care Licensing Department (CCLD) on 12/31/24 reporting a physical altercation between R1 and R2 that took place on 12/30/24. An SOC 341 report was also provided to CCLD, the Ombudsman and West Valley Police Department. LPA interviewed two (2) staff that were present during the fight. Two (2) staff that were present during the incident reported that R2 hit R1 in the facial area and the fight was stopped immediately by separating the two (2) residents from each other. Let it be noted, both residents are non-ambulatory and are in wheelchairs. Staff #1 (S1) reported that R2 hit R1 in the mouth area while in the dining hall. S1 immediately moved R2 away from R1 and staff #2 (S2) took R2 back to their room. S1 then called staff #3 (S3) to report the incident and R1 was given an ice pack to put around their mouth area which was bleeding. R1 was sent to the hospital and West Valley Police Department took a report on 12/31/24 of what had occurred. During LPA's interviews, R1 was able to tell LPA non-verbally by pointing at their mouth area when asked what happened between them and R2. When LPA interviewed R2, R2 admitted to hitting R1 because R1 was yelling and screaming. LPA interviewed thirteen (13) residents that confirmed when an incident occurs staff are helpful to them, and the staff seek medical attention if it is needed. Based on the LPA's observations and record reviews, staff and resident interviews conducted the allegation is UNSUBSTANTIATED at this time.

An exit interview was conducted, no citation(s) issued, and a copy of this report was given to the resident care director, Mary Jane Reyes.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025

LIC9099 (FAS) - (06/04)

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