197608267-3-26-2025-31-AS-TAGD-DFLUP3-20250410154452

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 03/26/2025
Date Signed: 03/26/2025 11:47:47 AM

Substantiated

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
08/13/2024 and conducted by Evaluator Gina Saucedo

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20240813145428

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: 110	DATE:	03/26/2025
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Kandace Vergara, Administrator		TIME COMPLETED:	12:01 PM

ALLEGATION(S):

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Resident sustained a fracture while in care

INVESTIGATION FINDINGS:

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On 03/26/25, at 9:20am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Administrator, Kandace Vergara. LPA explained the purpose of this visit was to deliver findings for this complaint.

On 08/13/24, the complaint was referred to Investigations Branch (IB) and accepted as a full investigation. It was assigned to Veronica Padilla. On 08/14/24, LPA Gina Saucedo initiated the twenty-four (24) complaint investigation. LPA asked for the census, staff, resident roster and conducted a physical tour.

LIC 9099C-continued

Substantiated

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: 03/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025

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-20240813145428

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: 03/26/2025

NARRATIVE

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Regarding the allegation: Resident sustained a fracture while in care. It is being alleged that resident #1 (R1) sustained a cervical neck fracture.

On 08/20/24, IB conducted a facility visit and received the following documents: August Staff Schedule, Staff Roster with contact information, Facility First Second Floor Facility Map, Daily Census, Unusual Incident/Injury Report, R1's File containing the following: Preplacement Appraisal Information, Functional Capability Assessment, Resident Appraisal, Appraisal /Needs and Services Plan, Personal Rights of Residents in Publicly Operated, House Rules, Guest Policy, Medication Disclosure and Policy, Private Caregiver, Home Health Agency, and Hospice Disclosure and Policy, Statement of Informed Choice, Unsupervised Absence Disclosure, Ambulation and Mobility, Dementia, Residence and Care Agreement, and Admission Agreement record review of hospital records from Kaiser Permanente. Furthermore, IB conducted interviews.

On 10/08/24, IB conducted another facility visit and interviewed additional staff and was informed that R1 might have had an unwitnessed fall during the night that caused the cervical fracture.

The investigation revealed the facility’s Neglect/Lack of Supervision contributed to the development of R1’s cervical fracture. Based on the observation of the IB Investigator, interviews conducted, and record review
the allegation is SUBSTANTIATED at this time.

An immediate Civil Penalty of $500.00 is being issued today, due to the staff’s negligence. Refer to LIC 421M.

At this time, an Enhanced Civil Penalty (ECP) determination is pending and may be assessed at a later date.

Exit interview conducted, appeal rights discussed, and a copy of the report was given to the administrator.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20240813145428

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/26/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/27/2025 Section Cited HSC 1569.269(a)(6)	1 2 3 4 5 6 7	§1569.269 Enumerated rights; severability(a) Residents of residential care facilities for the elderly shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met by:	1 2 3 4 5 6 7	Licensee/Administrator will provide training to all staff on mandatory reporting and the care, supervision and services to all residents. POC Cleared 03/27/25
	8 9 10 11 12 13 14	Based on the Investigator's Interviews the licensee/administrator failed to ensure the care, supervision and services of resident #1 (R1) while in the facility. This posed an immediate health and safety risk to residents 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 Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025

LIC9099 (FAS) - (06/04)

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