197608267-5-3-2022-31-AS-NGID-CECRQQ-20220512131356

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 05/03/2022
Date Signed: 05/03/2022 03:14:19 PM

Unsubstantiated

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
04/27/2022 and conducted by Evaluator Shira Stamps

COMPLAINT CONTROL NUMBER: 31-AS-20220427165510

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:	05/03/2022
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Aristotle Vergara, Administrator		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Facility electricity malfunctioned.

INVESTIGATION FINDINGS:

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On 5/3/22, Licensing Program Analyst (LPA) Shira Stamps arrived at the facility mentioned above to conduct an initial complaint visit. LPA met with the Administrator and explained the purpose of the visit. LPA conducted interviews from 10:30am-12:45pm. LPA requested documents (physician reports and appraisal needs and services) for residents interviewed.

Facility electricity malfunctioned.

It was alleged that the electricity went out three times at the facility. The dates of the outages were not provided. At 10:30am, LPA interviewed the Administrator who indicated the power went out a couple months ago due to a glitch, and stated the generator kicks on when the power goes out. The Administrator stated the Maintenance worker would have more information. At 10:35am, LPA interviewed the Maintenance worker who indicated there was a power surge that knocked out a breaker.
CONTINUED...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20220427165510

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: 05/03/2022

NARRATIVE

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The Maintenance worker indicated it took about twenty minutes to fix the issue, and that the electricity only went out one time. The Maintenance worker stated he fixed the issue and did not document it. LPA interviewed two (2) staff members that indicated the power went out once that day, but the issue was fixed the same the day. Six (6) out of ten (10) residents interviewed indicated there was no power outages. Two (2) out of ten (10) residents interviewed indicated there was a power outage that happened one time, that lasted less than an hour. Based on interviews, it was found that the electricity went out once and the issued was fixed the same day. Therefore, the allegation, “Facility electricity malfunctioned” is deemed unsubstantiated.

Exit interview conducted. Appeal rights and copy of report delivered to Administrator.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022

LIC9099 (FAS) - (06/04)

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