197608267-5-26-2021-31-AS-MVAO-CD7UVZ-20220405155558

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 05/26/2021
Date Signed: 05/26/2021 03:01:01 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
05/20/2021 and conducted by Evaluator Alexander Pitz

COMPLAINT CONTROL NUMBER: 31-AS-20210520141239

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: 112	DATE:	05/26/2021
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Lourdes Kazdan		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

1
2
3
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5
6
7
8
9

Facility is not releasing resident's records to authorized representative.

INVESTIGATION FINDINGS:

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2
3
4
5
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7
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9
10
11
12
13

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

As part of this investigation LPA reviewed relevant interviewed a relevant witness (W1) and facility staff member (S1) in addition to reviewing relevant client records for resident 1 (R1).

Allegation #1, that "Facility is not releasing resident's records to authorized representative," has been substantiated based on the interviews conducted and records reviewed. LPA confirmed that R1's records from the facility were requested by their responsible party/ next of kin on 4/8/21, 4/27/21, 5/6/21, and 5/20/21 but have not yet been provided.
Report reviewed and delivered, exit interview conducted. A hard, signed, copy of this report will be kept in the facility's file.

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: 05/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021

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-20210520141239

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: 05/26/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/09/2021 Section Cited CCR 87468.2(a)(19)	1 2 3 4 5 6 7	87468.2(a)(19) To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies.	1 2 3 4 5 6 7	Facility will comply with the lawful request for resident records by the R1's responsible party/ next of kin.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Facility did not provide resident records to aurhotized representative within 2 days of it being requested which poses a potential risk to the personal rights of clients 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: 05/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021

LIC9099 (FAS) - (06/04)

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