197608267-11-16-2020-31-AS-EMIR-CD3TDU-20220401143857

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 11/16/2020
Date Signed: 11/16/2020 12:19:12 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
11/10/2020 and conducted by Evaluator Alexander Pitz

COMPLAINT CONTROL NUMBER: 31-AS-20201110164740

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: 121	DATE:	11/16/2020
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Mary Jane Reyes		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff mismanages resident's medication.
Staff did not administer resident's medication as prescribed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Pitz initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with lead staff Mary Jane Reyes.

As part of this investigation, LPA Pitz conducted telephone interviews with lead staff Mary Jane Reyes, a facility medication technician, and the complainant. LPA also conducted a virtual review of Resident 1's (R1's) Medication Assistance Record. LPA requested copies of Resident 1's (R1's) entire facility file be sent directly to LPA via email.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Alexander Pitz	TELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2020

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 3

Control Number 31-AS-20201110164740

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: 11/16/2020

NARRATIVE

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Allegation #1, that "Staff mismanages resident's medication," has been substantiated based on the interviews conducted, observations made, and credible nature of the complainant. The complainant alleged, and both staff interviewed confirmed, that R1 received their medication on 11/6/20, and should have received it again on 11/9/20. Both staff also stated that medications like R1's are normally supposed to be ordered at least a week in advance, but confirmed the complainant's allegation that this was not done until 11/6/20 when the last dose was given. All parties agreed that the medication was then not picked up until 11/10/20.

Allegation #2, that "Staff did not administer resident's medication as prescribed," has been substantiated based on the interviews conducted, observations made, and credible nature of the complainant. Due to the above described mismanagement, both staff confirmed the complainant's allegation that R1 should have received their medication on 11/9/20, but did not receive it until the following day. LPA also observed the facility's Medication Assistance Record to not have recorded this medication as being passed at any time in November prior to 11/10/20, even though the medication was begun on 10/22/20 and is supposed to be administered every three days.

A telephonic exit interview was conducted with staff, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Alexander Pitz	TELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2020

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20201110164740

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: 11/16/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/18/2020 Section Cited CCR 87465(a)(5)	1 2 3 4 5 6 7	87465(a)(5) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility will review and conduct a training with all medication technicians on facility's medication procedures. A copy of the sign-in sheet from this training will be provided to LPA by the indicated date.
	8 9 10 11 12 13 14	Based on interviews and observations, the facility did not order R1's medication to be refilled in a timely manner and did not pick it up as soon as it was ready, which lead to R1 receiving it on 11/10/20 instead of 11/9/29 which poses an immediate risk to the resident 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: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Alexander Pitz	TELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2020

LIC9099 (FAS) - (06/04)

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