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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 04/22/2022
Date Signed: 04/22/2022 01:19:56 PM

Substantiated


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
07/12/2021 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20210712154639
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: 105DATE:
04/22/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Kandice Vergara TIME COMPLETED:
12:40 PM
ALLEGATION(S):
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Resident sustained pressure injuries while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent visit to finish investigation into the allegation above. LPA met with facility staff and explained the reason for this visit.
This investigation was conducted by Investigator Olivia Spindola from IB (Investigations Branch). It is alleged that resident #1 (R1) sustained pressure injuries while in care. During the investigation Investigator Spindola conducted a visit and interviewed 5 staff members and one resident on 7/22/21; interviewed a staff member on 8/23/21; Reviewed medical records on 9/11/21 and 9/14/21; conducted witness interviews on 9/14/21; reviewed records on 9/19/21 and 10/6/21. Initial complaint visit was conducted on 7/13/21 by LPA Pitz. During that visit the facility’s Administrator and Wellness Coordinator told LPA Pitz that R1 was not receiving any sort of wound care treatment from their Home Health Agency and did not have any pressure injuries they were aware of, while the Wellness Director, staff #1 and MedTech all said that R1 was receiving wound care treatment from their home health nurse.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
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-20210712154639
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: 04/22/2022
NARRATIVE
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Medical records received and reviewed on 9/19/21 from Dignity Health Northridge Hospital Medical Center indicate that on 7/8/21 R1 was admitted to the hospital with stage three pressure injuries on their sacrum and coccyx. Hospital records also indicate that “[patient] stated that [they have] had wounds for the past 3 months. Wounds appear as [patient] is not receiving appropriate care at the facility.” Based on the information obtained from interviews and record review this allegation is deemed Substantiated. Deficiency cited on LIC 9099 D. Appeal Rights explained. Exit Interview conducted.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20210712154639
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: 04/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/25/2022
Section Cited
CCR
87615(a)(1)
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Prohibited Health Conditions-Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly.Stage 3 and 4 pressure injuries.
This requirement was not met as evidenced by:
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Administrator will provide proof of all direct care staff undergoing training from an approved vendor on the topic of prohibited health conditions.
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Based on interviews and documentation obtained R1 developed multiple stage 3 pressure injuries while in the facility. This posed an immediate health and safety risk to residents in care.
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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 HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3