197608267-6-11-2021-31-AS-MVAO-CD825W-20220405170614

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 06/10/2021
Date Signed: 06/11/2021 01:29:41 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
06/09/2021 and conducted by Evaluator Alexander Pitz

COMPLAINT CONTROL NUMBER: 31-AS-20210609135508

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: 107	DATE:	06/10/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Aris Vergara		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Facility roof is in disrepair

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Pitz conducted an unannounced visit on this date in response to the above allegation.
As part of this investigation, LPA interviewed three staff members, two residents, and conducted a physical inspection of Resident 1's (R1's) and Resident 2's (R2's) rooms.

Allegation #1, that the "facility roof is in disrepair" has been substantiated based on the interviews conducted and observations made. LPA observed R1's ceiling to still be under construction, which has caused R1 to remain in a temporary room without all of their belongings. LPA confirmed that this arrangement has persisted since March 13, 2021. Facility administrator was able to demonstrate that another resident's leaky ceiling has already been repaired, but stated that repairs have been delayed in R1's room due to covid.
Report reivewed and deliverd, exit interview conducted and deficiencies cited. A signed hard copy of this report will be returned to LPA via email and 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: 06/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021

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 4

Control Number 31-AS-20210609135508

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: 06/10/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/24/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will provide proof of progress being made on roof repairs, including but not limited to: quotes, invoices, and pictures.
	8 9 10 11 12 13 14	The facility has not ensured that the roof above R1's room was repaired in a timely fasion, which poses a potential risk to residents 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: 06/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4

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
06/09/2021 and conducted by Evaluator Alexander Pitz

COMPLAINT CONTROL NUMBER: 31-AS-20210609135508

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: 107	DATE:	06/10/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Aris Vergara		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Staff did not safeguard resident's personal items
Staff confiscated resident's alcoholic beverages

INVESTIGATION FINDINGS:

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

As part of this investigation, LPA interviewed three staff members and one resident (R1). LPA also reviewed relevant facilty records.

Allegation #1, that "Staff did not safeguard resident's personal items," has been unsubstantiated based on the records reviewed and interviews conducted. LPA confirmed that R1 is self-responsible and refused to list any items on his Resident Personal Property and Valuables form. LPA also confirmed that the facility attempted to replace R1's phone that was damaged by leaking water, but R1 refused. R1 admitted that the other damage to his belongings was the result of an accident that he caused.

Unsubstantiated

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: 06/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 31-AS-20210609135508

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: 06/10/2021

NARRATIVE

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Allegation #2, that "Staff confiscated resident's alcoholic beverages" has been unsubstantiated based on the interviews conducted and observations made. R1 confirmed that they have received their alcohol and that this is no longer an issue. Facility staff provided a doctor's order showing that R1's alcohol intake is to be monitored and controlled, and the facility is taking appropriate steps to respect R1's personal rights while also ensuring their safety as well as that of the other residents.

Report reviewed and delivered, exit interview conducted. A signed hard copy of this report will be returned to LPA via email and kept in the facility's file.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Alexander Pitz	TELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4