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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 11/05/2021
Date Signed: 11/05/2021 01:13:49 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/14/2020 and conducted by Evaluator Alexander Pitz
COMPLAINT CONTROL NUMBER: 31-AS-20200714171154
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: 108DATE:
11/05/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Aris VergaraTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Resident has multiple unstageable pressure injuries
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Pitz initiated a complaint investigation visit on this day for the purpose of delivering the Investigation Branch’s (IB’s) findings on the above allegations.
Allegation #1, that “Resident has multiple unstageable pressure injuries”, has been substantiated based on the records reviewed and the credible nature of the reporting party. During the course of the investigation, it was revealed that former Resident #1 (R1) indeed sustained several pressure injuries during their stay at the facility. Per medical documents obtained during the investigation, it was indicated that upon admission to Northridge Hospital Medical Center on 7/5/20 R1 had sustained two “unstageable” pressure injuries on their back, as well as an unstageable pressure injury on their right heel and sacrum. While residing at the facility, R1 was receiving home health services for wound care prior to being hospitalized but was not on hospice. The reporting party, a credible source, stated that the wound “could have been preventable if resident was regularly turned and cared for appropriately.”
An exit interview was conducted with the Administrator, and a hard copy of the report and appeal rights was delivered.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 31-AS-20200714171154
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/12/2021
Section Cited
CCR
87615
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87615(a)(1) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: Stage 3 and 4 pressure injuries.
This requirement is not met as evicenced by:
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Administrator will provide proof of all direct care staff undergoing training from an approved vendor on the topic of prohibited health conditions.
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Based on record review the licensee did not ensure that Resident 1 did not contract a prohibited health condition while at the facility which posed an immediate 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 MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2