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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608267
Report Date: 11/29/2021
Date Signed: 11/29/2021 02:51:51 PM

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: DATE:
11/29/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Aristotle Vergara, AdministratorTIME COMPLETED:
03:00 PM
NARRATIVE
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At approximately 10:20am Licensing Program Analysts (LPAs) Shira Stamps and Angela Panushkina made an unannounced case management visit regarding an eviction notice. LPAs were greeted by staff, Steven Hang and Stone Acevedo. LPAs were asked to sign in, to answer COVID symptom questions, and temperatures were taken. LPAs met with Lourdes Kazdan(LK), the resident care director; and Mary Jane Reyes (MR), the wellness director, at approximately 10:32am., and explained the purpose of the visit. LPAs requested LIC 500, Resident roster, and documentation of the incident reports for the resident in question. LPA team interviewed LK and MR around 10:35am regarding the eviction notice. LK stated they have kept documentation of all incidents that occurred for the resident in question. LPAs reviewed Richard Scharfenstein's (R1) one (1) incident report and documentation of other incidents at approximately 2:00pm. LPAs reviewed previously submitted incident report history ,and did not find any reports that were provided/faxed to Community Care Licensing Department (CCLD). At 2:00pm, LPA team was given a copy of the eviction notice that was provided to R1 by the Administrator dated 11/10/21. Upon review, it was observed to be non-compliant under Title 22 regulation because it lacked the following information:

(A) Failure to submit incident reports/documentation to CCLD to support the eviction notice.

(B) Eviction notice was delivered to R1 before it was approved by CCLD.

Based on the interview conducted with LK and MR,and the relevant documentation obtained, the eviction is not approved.



Report reviewed, signed, and delivered. Exit interview conducted, appeal rights issued and deficiencies on 809-D page.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira StampsTELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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, THE
FACILITY NUMBER: 197608267
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/14/2021
Section Cited

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87224(a)(4) Eviction Procedures: The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5)

This requirement is not met as evidenced by:
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Based on the interviews and record review, the Administrator did not comply with the section cited above by not providing an eviction notice for an approval with supporting documents (SIRs,Resident Appraisal) to Community Care Licensing Department, which poses a potential health and safety risk to persons in care.
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-Submit a new eviction notice to CCLD for approval before delivering it to the resident or resident’s responsible party.
Type B
12/14/2021
Section Cited

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87211(a)(1)(D) Reporting Requirements:
The licensee shall send a written report, within seven days, to the licensing agency and the person responsible for the resident when any incident occurs which threatens the welfare, safety or health of any resident.

This requirement is met as evidenced by:
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Baed on the documents provided, on 9/11/21 R1 had a knife in possession and threatened someone with it, this incident was not reported to CCLD.

R1 had eight (8) more incidents of aggressive behavior on 10/28/21- 10/30/21 and 08/22/21-08/23/21 that were not reported to CCLD. This poses a potential health and safety risk 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.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira StampsTELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2021
LIC809 (FAS) - (06/04)
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