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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608267
Report Date: 07/13/2021
Date Signed: 07/13/2021 01:33:58 PM

Document Has Been Signed on 07/13/2021 01:33 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:CEDARS ASSISTED LIVING, THEFACILITY NUMBER:
197608267
ADMINISTRATOR:ARISTOTLE B. VERGARAFACILITY TYPE:
740
ADDRESS:17300 ROSCOE BLVD.TELEPHONE:
(818) 344-2042
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 175CENSUS: 111DATE:
07/13/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Aris VergaraTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Pitz conducted an unannounced Case Management visit on this day in order to address deficiencies observed during a complaint investigation visit for complaint control # 31-AS-20210712154639.


At 12:15PM LPA was handed the file for resident 1 (R1) and observed the most recent appraisal to be from 9/11/18.

At 1:00PM LPA reviewed the home health file for R1 and observed there to be no written agreement signed by the facility and the agency outlining the responsibilities of each.


Report reviewed, signed and delivered. Exit interview conducted, deficiencies on 809D page.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Alexander Pitz
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2021
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 07/13/2021 01:33 PM - It Cannot Be Edited


Created By: Alexander Pitz On 07/13/2021 at 12:50 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/06/2021
Section Cited
CCR
87463(c)

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87463(c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months...
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Administrator agrees to review all resident appraisals to ensure they are updated and signed. A signed statement of completion, along with a copy of R1's updated appraisal will be provided by the indicated date.
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This requirement is not met as evidenced by:

Based on resident record review and staff interview, the facility did not ensure that Resident 1's (R1's) appraisal was updated within the last 12 months which poses a potential risk to residents in care.
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Type B
07/27/2021
Section Cited
CCR87609(b)(4)

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87609(4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident’s medical condition(s).

This requirement is not met as evidenced by:
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Administrator agrees to provide a copy of a complete, correct home health agreement for Resident 1 (R1), as well as a list of all other residents receiving Home Health or Hospice services and a statement confirming that their records have been updated as well.
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Based on file review, the facility did not ensure that a signed,written agreement outlining facility responsibilites was maintained in the residents file which poses a potential risk to residents 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.
SUPERVISOR'S NAME:Eva Miller
LICENSING EVALUATOR NAME:Alexander Pitz
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2021


LIC809 (FAS) - (06/04)
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