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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608267
Report Date: 05/02/2022
Date Signed: 05/02/2022 04:29:14 PM


Document Has Been Signed on 05/02/2022 04:29 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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, THEFACILITY NUMBER:
197608267
ADMINISTRATOR:ARISTOTLE B. VERGARAFACILITY TYPE:
740
ADDRESS:17300 ROSCOE BLVD.TELEPHONE:
(818) 344-2042
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY:175CENSUS: 107DATE:
05/02/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Aris Vergara TIME COMPLETED:
04:35 PM
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On 05/02/22 Licensing Program Analyst (LPA) Joscelyn Martinez conducted an unannounced Case Management Visit to address an incident report received on 04/19/22. LPA met with Administrator Aris Vergara and the purpose of the visit was explained.

On 04/16/22 R2 reported to staff and law enforcement that they witness Staff one (S1) slapping Resident one (R1) in the face because R1 was trying to leave the memory care unit. Law enforcement did not take a report and did not make any arrests. There was insufficient evidence that S1 had physically slapped R1.

Interviews conducted today revealed that R1 was trying to get out of the memory care unit where they reside. R2 noticed that R1 was trying to get out and opened the Egress door leading into the memory care unit. The Egress alarm activated, and S1 responded to the alarm. S1 attempted to redirect R1 back inside the unit and this is when R2 reported to witness S1 slapping R1. When law enforcement interviewed S1 and R1 and both denied that S1 had slapped R1. Relevant documents were obtained.

Further investigation is needed at the moment. Exit interview conducted. Report signed and delivered.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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