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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 03/26/2022
Date Signed: 03/28/2022 11:13:20 AM



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
04/02/2021 and conducted by Evaluator Wendell Smith
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20210402122430
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: 110DATE:
03/26/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Lourdes KazdanTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff caused injuries to a resident while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent visit to finish investigation into the allegation above. LPA met with facility staff and explained the reason for this visit.

Investigation was conducted by Investigations Branch (IB) Investigator Douglas Real. It is alleged that facility staff failed to provide an appropriate level of supervision which resulted in resident #1 (R1) sustaining a fall which caused a fracture and several wounds. Investigation consisted of a review of R1’s hospital records, interviews with facility staff, hospice staff, and hospice staff owner on 6/08/21. Information from interviews reveal that R1 was taken to the hospital on 4/1/21 after sustaining a fall in their room. R1’s medical records show R1 sustained a left arm skin tear, laceration over right lower leg, laceration over left ankle, and a right leg fracture. No abuse or neglect concerns were reported. Interviews reveal that when R1 fell in their room, hospice staff was present and treating R1. Based on the information obtained through
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2022
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-20210402122430
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: 03/26/2022
NARRATIVE
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medical record review and interviews, it was revealed that R1’s fall and injuries were not the result of facility staff negligence. Therefore, this allegation is deemed unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Appropriate cross reports will be made for this case.

Exit interview conducted.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2