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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 12/16/2021
Date Signed: 12/16/2021 03:00:02 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
12/10/2021 and conducted by Evaluator Shira Stamps
COMPLAINT CONTROL NUMBER: 31-AS-20211210144815
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: DATE:
12/16/2021
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Aristotle Vergar ,AdministratorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility evicted resident after resident filed a complaint
INVESTIGATION FINDINGS:
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At 1:15pm Licensing Program Analyst (LPA) Shira Stamps arrived at the facility mentioned above for an initial complaint visit. Entrance interview conducted.

At approximately 1:20 pm, LPA conducted a physical plant walk through, and LPA did not observe any immediate health and safety issues during this visit. From 1:45pm-2:30pm, LPA conducted interviews with three (3) staff members, one (1) witness, and reviewed documents.

Allegation: Facility evicted resident after resident filed a complaint.

Interviews with three (3) out of three (3) staff members stated the resident had a history of breaking house rules. Three (3) out of three (3) staff members stated the resident in question was warned about having a stove in the room and smoking in the room and the facility hallway. Three (3) out of three (3) staff members stated the resident was previously given two eviction warnings for breaking house rules. Continued...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira StampsTELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021
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 2
Control Number 31-AS-20211210144815
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: 12/16/2021
NARRATIVE
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One (1) witness stated the resident in questions was previously warned two times about breaking house rules. Therefore, after review of the documents received and the interviews conducted the allegation, “Facility evicted resident after resident filed a complaint,” is deemed unsubstantiated.

Exit interview conducted. Report delivered.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira StampsTELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2