197608267-6-16-2021-31-AS-MVAO-CD7VG2-20220405162450

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 06/16/2021
Date Signed: 06/16/2021 12:51:03 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
05/18/2021 and conducted by Evaluator Alexander Pitz

COMPLAINT CONTROL NUMBER: 31-AS-20210518111722

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:	06/16/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Aris Vergara		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility did not take appropriate measures to safeguard resident's SSI benefits.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
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 interviewed three staff members and reviewed resident records on 5/26/21. LPA also interviewed the complainant and three staff members, in addition to reviewing more client records on 6/1/21.

Allegation #1, that the "Facility did not take appropriate measures to safeguard resident's SSI benefits" has been substantiated based on the records reviewed and interviews conducted. On 6/1/21 LPA spoke with the complainant, a credible witness, who stated that the facility is the official Social Security Administration (SSA) payee for Resident 1 (R1), and that R1 is losing their Social Security Income (SSI) due to the facility's mismanagment of R1's funds.

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: 06/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

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 3

Control Number 31-AS-20210518111722

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: 06/16/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On 5/26/21 and 6/1/21 LPA spoke with a total of four staff members, including the "Residential Care Coordinator," the "Wellness Coordinator," the "Business Office Director," and the "Business Office Assistant." All four staff members confirmed that there is a past due rent balance for R1 of $21,013.66, and that R1 also has a large sum of money in their checking account which is causing their SSI benefits to be discontinued. 4/4 of the staff interviewed between 5/26/21 and 6/1/21 were unable to give a definitive confirmation of whether the facility is R1's payee or not. SSA letters received from the facility on 5/26/21 confirm that on 8/12/2020 the facility was selected by SSA to be R1's payee. A subsequent letter addressed to the facility on R1's behalf, dated 4/13/21, confirms that R1's benefits were being discontinued due to an accrued balance of $24,000 in their account.

Report reviewed and delivered. Exit interview conducted, deficiencies cited. A signed hard copy of this report

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander Pitz	TELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20210518111722

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: 06/16/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/23/2021 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2(a)(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility will provide a complete accounting of the timeline of events leading up to this complaint and through the present, along with their plan to rectify the situation. Facility will also provide a complete ledger of funds for all residents for whom they are the SSI payee.
	8 9 10 11 12 13 14	Based on interviews and record review, the facility did not ensure that R1's SSI benefits were withdrawn from their account, which poses a serious risk the health, safety or personal rights of 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: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Alexander Pitz	TELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3