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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 10/25/2021
Date Signed: 10/25/2021 03:14:08 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
09/28/2021 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20210928124225
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: 102DATE:
10/25/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Aristotle VergaraTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility not maintained clean and sanitary
Facility has pests
Facility does not meet residents' nutritional needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst(s) Wendell Smith and Jocelyn Martinez conducted an unannounced subsequent visit to this facility to investigate the allegation above. LPA's met with the administrator and explained the reason for this visit.

Facility not maintained clean and sanitary
Initial visit was conducted on 9/29/21 to began investigation into this allegation. On 10/4/21 a Required Annual visit was conducted where a physical plant tour was conducted. During the physical plant tour it was observed that rooms 107 and 109 had a strong foul odor coming from them. In room 108 there was no running water. On the second floor of the facility the dining room tables and flooring were in disrepair. Based on the information obtained during the visit on 10/4/21 this allegation is deemed Substantiated. Deficiency cited on LIC 9099 D.
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: 10/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021
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 6
Control Number 31-AS-20210928124225
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: 10/25/2021
NARRATIVE
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Facility has pests
It is alleged that the facility had an issue with pest in the facility. LPA conducted an interview with the administrator regarding this allegation from approximately 11am-11:15 am. Administrator admitted that there was an issue with roaches in the facility and they had a pest control company come to the facility and spray certain areas that were affected by pest. LPA obtained copies of the pest control company report. Based on the information obtained through interviews this allegation is deemed Substantiated. Deficiency cited on LIC 9099 D.

Facility does not meet residents' nutritional needs
It is alleged that the food served is not of good quality. Interviews were conducted with residents from 10:00-11:30am. Interviews revealed that the food served sometimes not cooked properly, overcooked, and bland. This allegation has been addressed today on complaint control number 31-AS-20211020122325. This allegation is Substantiated but it will not be cited on this report due to being addressed on complaint control number 31-AS-20211020122325.
Exit Interview conducted. Appeal Rights explained. Copy of report emailed to administrator.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 31-AS-20210928124225
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: 10/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2021
Section Cited
CCR
87303(a)
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Maintenace and Operation-The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement was not met as evidenced by:
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Administrator submitted copies of pest control invoices to LPA to show the pest control issue has been addressed. Issue with parts of the facility being in good repair has already been addressed previously.
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Based on interviews conducted it was found that the facility did have an issue with pest and that some rooms and parts of the facility were not clean and in good repair which posed a potential 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: 10/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
09/28/2021 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20210928124225

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:
10/25/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Aristotle VergaraTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff do not properly supervise resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst(s) Wendell Smith and Jocelyn Martinez conducted an unannounced subsequent visit to this facility to investigate the allegation above. LPA's met with the administrator and explained the reason for this visit.

Regarding the allegation above it is alleged that facility staff do not provide proper supervision of resident # 3 (R3) due to R3 harassing other residents and starting fights with other residents. It is alleged that facility staff do not intervene or do anything to stop R3 from doing this to other residents. During the initial visit conducted on 9/29/21 LPA's interviewed the administrator and obtained copies of pertinent information related to this allegation. Information from interviews reveal that there have been several incidents involving R3 and the facility has intervened and called law enforcement several times. LPA received copies of serious incident reports and copies of cards issued by law enforcement when they had to come to the facility to deal with R3. On 9/23/21 R3 was sent to the hospital due to an altercation with another resident. R3 was due to get an eviction notice, but after going to the hospital R3 never came back to the facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 31-AS-20210928124225
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: 10/25/2021
NARRATIVE
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During a previous visit LPA Martinez observed an incident with R3 attacking another resident and observed staff intervene. Based on the information obtained through interviews and records obtained this allegation is deemed Unsubstantiated at this time. Exit interview conducted.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6