197608267-11-29-2021-31-AS-NGID-CABVEY-20220103152306

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 11/29/2021
Date Signed: 11/29/2021 02:53:14 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
11/24/2021 and conducted by Evaluator Shira Stamps

COMPLAINT CONTROL NUMBER: 31-AS-20211124093048

FACILITY NAME:	CEDARS ASSISTED LIVING, THE		FACILITY NUMBER:	197608267
ADMINISTRATOR:	ARISTOTLE B. VERGARA		FACILITY TYPE:	740
ADDRESS:	17300 ROSCOE BLVD.		TELEPHONE:	(818) 344-2042
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY:	175	CENSUS:	DATE:	11/29/2021
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Aristotle Vergara, Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Unlawful Eviction- Resident #1 (R1) was not accepted back to the facility upon discharge from the hospital on 11/17/2021.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Shira Stamps arrived at the facility to conduct an initial complaint visit for the allegations mentioned above. LPA met with the Administrator and wellness care director, and explained the purpose of this visit.
It was alleged that Resident #1 (R1) was not accepted back to the facility upon discharge from the hospital on 11/17/2021.
During this investigation at approximately 10:23am, LPA conducted a physical plant tour and did not observe any immediate health and safety issues.
At 11:00am, LPA conducted interviews with the Administrator, and other staff. In addition, LPA spoke with the witnesses that were able to provide pertinent information regarding R1’s care and supervision, as well as, their health care needs.

Continued...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20211124093048

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
	VISIT DATE: 11/29/2021

NARRATIVE

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The Administrator stated that R1 was sent to the Psych Ward for a 72 hour hold. Although no eviction letter was served to R1, upon discharge, he refused to accept R1 back due to the facility's inability to provide care and supervision R1 required. Additional interviews of the staff and witnesses revealed that at the time of R1’s discharge, staff did not review R1’s discharge records and did not reassessed the resident to ensure if R1 did require higher level of care.

A review of R1’s facility records conducted at 11:20am, revealed, that since admission, there are no changes in R1’s health condition. No changes in R1's behavior was noted in any facility records.
Based on interviews and record review, there is sufficient information to support the allegation.
Therefore, the allegation is SUBSTANTIATED at this time.

Under Title 22, Division 6, Chapter 8, the following Deficiency was cited and recorded on LIC9099D.
Exit interview conducted, appeal rights discussed and a copy of report was delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20211124093048

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: 11/29/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/09/2021 Section Cited CCR 87224(a)(4)	1 2 3 4 5 6 7	87224 Eviction Procedures. (a)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…If, after admission, it is determined that the resident has a need not previously identified,	1 2 3 4 5 6 7	The Administrator states that he will submit a signed written statement that regulation 87224 has been read and understood and that the Administrator will comply with eviction procedures in the future. Submit to LPA by 12/09/21
	8 9 10 11 12 13 14	a reappraisal has been conducted … and the licensee… believe that the facility is not appropriate for the resident. This requirement is not met as evidenced by. Prior to refusal to accept R1 back to the facility, the Administrator did not conduct a reappraisal and serve a 30-day written eviction notice.	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: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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