197608267-11-5-2021-31-AS-EMIR-CCZUW9-20220330155623

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 11/05/2021
Date Signed: 11/05/2021 01:37:17 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
11/09/2020 and conducted by Evaluator Alexander Pitz

COMPLAINT CONTROL NUMBER: 31-AS-20201109133407

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: 108	DATE:	11/05/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Aristotle Vergara		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Resident suffered multiple falls while in care.
Resident is malnourished.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) conducted an unannounced visit on this day in response to the above allegations.

As part of this investigation, LPA conducted a telephonic visit and interviewed two staff members on 11/16/20; interviewed a relevant witness on 11/16/20, 12/28/20, 1/28/21; reviewed records obtained from the facility for Resident 1 (R1) on 11/16/20; reviewed medical records obtained via subpoena from Northridge Medical Center and 360 Home Health; reviewed the Woodland Hills South Regional Office (WHSRO) file for incident reports on 11/5/21; interviewed the administrator on 11/5/21 and collected additional records.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander Pitz	TELEPHONE: (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)

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Control Number 31-AS-20201109133407

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: 11/05/2021

NARRATIVE

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Allegation #1, that "Resident suffered multiple falls while in care" has been substantiated based on the records reviewed and interviews conducted. A review of R1’s Home Health Agency’s (HHA’s) communication log with the facility indicates that on 10/31/20 at 5:24pm R1’s nurse was informed “Per facility PCG report: patient fell from the bed while was trying to get up unassisted.” A review of the admission records for R1 at Northridge Hospital Medical Center on 11/5/21 indicate that a X-ray of the chest revealed “multiple left-sided rib fractures, which are new since prior study dated June 10, 2020.” However, both staff interviewed by LPA on 11/16/20 denied that R1 had experienced any recent falls, and the only incident report ever submitted by the facility for R1 was when they were hospitalized on 11/5/20 for “low intake” and “low reading results from blood pressure.”
Allegation #2, that “Resident is malnourished” has been substantiated based on the records reviewed and interviews conducted. On 11/16/20 LPA interviewed the facility’s Wellness Director telephonically and they stated that R1 had been recently hospitalized for “general weakness” and confirmed that they were “always refusing meals,” but denied that R1 had experienced any sort of "rapid or concerning weight loss.” LPA was informed by W1 though that on 11/5/20 W1 was informed by R1’s Home Health nurse that R1 appeared malnourished. A review of R1’s HHA’s communication log with the facility for 11/5/20 at 11:08 am shows that “per facility staff report: patient is weak, refused to eat since yesterday...” A review of the facility’s food intake record for R1 for November 2020 shows that significant percentages of food and fluid intake were still being recorded from 11/1/20-11/4/20, however, the Northridge Medical Center admission record from 11/5/20 indicates that “In the emergency department the patient was found to be significantly dehydrated with acute renal failure and he was admitted for further evaluation and treatment.” R1 was given IV fluids, antibiotics to treat aspiration pneumonia, and discharged to a Skilled Nursing Facility.

Report reviewed, signed and delivered. Exit interview conducted

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander Pitz	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20201109133407

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 87464(f)(1)	1 2 3 4 5 6 7	87464(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).	1 2 3 4 5 6 7	Administrator will provide proof of having obtained training from an approved vendor for all direct care staff on the topic of fall prevention.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on recrods reviewed and interviews conducted, the facility did not ensure that sufficient care and supervision was provided to R1 to prevent a series of falls which poses an immediate risk to residents in care.	8 9 10 11 12 13 14
Type A 11/12/2021 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability...	1 2 3 4 5 6 7	Administrator will provide proof of having obtained training from an approved vendor for all direct care staff on the topic of observing residents in changes of condition.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, the facility did not ensure that R1's deteriorating condition was documented and responded to in a timely fashion which posed an immediate risk to residents in care.	8 9 10 11 12 13 14

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 Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander Pitz	TELEPHONE: (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)

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