197608267-6-29-2021-31-AS-MVAO-CD8SDR-20220406134733

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 06/29/2021
Date Signed: 06/29/2021 02:09:27 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
06/18/2021 and conducted by Evaluator Alexander Pitz

COMPLAINT CONTROL NUMBER: 31-AS-20210618160146

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: 111	DATE:	06/29/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Aris Vergara		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff does not provide activities for residents.
Staff isolates residents.

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 reviewed the documentation provided by a credible third party, conducted tours of the facility, reviewed the activity calendars, activity supplies and interviewed numerous residents and staff.

Allegation #1, that "Staff does not provide activities for residents" has been substntiated based on the records reviewed and interviews conducted. A credible reporting party states that on 2/12/21 the facility was observed to have activity schedules from December posted, multiple residents were observed with nothing to do, and the memory care unit (MCU) TV was broken.

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: 06/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021

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 3

Control Number 31-AS-20210618160146

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: 06/29/2021

NARRATIVE

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On 5/3/21 a credible reporting party stated that they observed 6 residents in the MCU with no activities to do, no activity calendar was posted, and the MCU TV was still broken. On 6/23/21 LPA Pitz conducted staff and client interviews at 11:00 a.m. 3/3 residents interviewed on that date stated that there were little or no activities provided at the facility. The facility administrator, Wellness Coordinator, and Residential Care Director all confirmed that the facility's activity coordinator was laid off some time around June 2020. The only activity calendar that could be obtained during the visit was for April 2021; a calendar for June 2021 was subsequently provided via email. On 6/29/21 at 11:00 a.m. 7/7 residents interviewed stated there were little to no activities provided at the facility, and LPA observed the facility to not be adhering to the scheduled activity for that time (Coloring at 10:30). LPA asked to see the coloring materials and was shown one box of crayons with some coloring book pages, staff stated it had not been provided as an activity today. LPA observed the MCU TV to still be broken.

Allegation #2, that "Staff isolates residents" has been substantiated based on the information provided by a credible reporting party as well as the client interviews conducted and incident reports reviewed. On 2/12/21 a credible reporting party identified three residents experiencing suicidal thoughts. On 5/3/21 a credible reporting party stated that 6 residents expressed thoughts of loneliness and isolation, and reported two suicide attempts at the facility within the last year. On 6/23/21 at 11:00 am LPA interviewed residents and 3/3 expressed feelings of loneliness, isolation and depression. On 6/29/21 at 11:00 a.m. LPA conducted a review of facility incident reports and interviewed 7 residents. 7/7 Residents interviewed expressed feelings of loneliness, isolation, or depression. LPA confirmed that on 4/26/20 and 5/9/21 two different residents attempted to commit suicide, LPA was able to interview one of them and confirmed that this was due to feelings of isolation and depression.

Report reviewed, signed and delivered. Exit interview conducted, deficiencies cited on 9099-D page, appeal rights given.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander Pitz	TELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20210618160146

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: 06/29/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/13/2021 Section Cited CCR 87461(a)(4)	1 2 3 4 5 6 7	87461(a) The facility shall determine the amount of supervision necessary by assessing the mental status of the prospective resident to determine if the individual:(4) actively participates in social activities or is withdrawn; This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will assess the emotional/ social state of all residents in care. Findings from this assessment will be shared with LPA, along with a plan for how to better address the feelings of isolation and depression among residents that will include a survey of requested/ preferred activities of the residents.
	8 9 10 11 12 13 14	Based on client interviews, a review of incident reports, and the reporting from a credible witness the facility did not ensure that residents who have withdrawn socially are being monitored and supervised appropriately which poses an immediate risk to the health, safety and personal rights of residents in care.	8 9 10 11 12 13 14
Type B 07/13/2021 Section Cited CCR 87219(a)	1 2 3 4 5 6 7	87219(a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will provide proof of a dedicated full time activity coordinator being hired by the facility, along with an updated calendar of activities for July and August to include activities added as a result of the survey conducted as part of the plan of correction for the above violation of 87461(a)(4)
	8 9 10 11 12 13 14	Based on observations and interviews, the facility did not ensure that activities are regularly scheduled and provided for residents which poses a potential risk to the health, safety and personal rights of 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: 06/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021

LIC9099 (FAS) - (06/04)

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