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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608267
Report Date: 10/28/2020
Date Signed: 10/28/2020 03:54:27 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
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: 120DATE:
10/28/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Aris VergaraTIME COMPLETED:
03:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Smith conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint control # 31-AS-20200514134611). The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation, conducted by LPA Amin, which were not related to the complaint. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s case management visit was conducted virtually via FaceTime with Aris Vergara.

During the complaint investigation, it was found that resident #1’s (R1) gold wedding ring was missing upon R1’s death. The ring was identified on R1’s LIC 621 Client/Resident Personal Property and Valuables form. After the ring was found missing, the facility staff failed to follow the theft and loss policy and report the missing ring to the local law enforcement agency. In addition, the facility staff failed to report R1’s visit to the emergency room on 3/31/20 and R1’s death on 4/22/20. In addition, the admission agreement in the office public file and the one that R1 signed are not the same and it does not meet all requirements per regulations. Therefore, the following deficiencies shall be issued.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Exit interview conducted. Appeal rights provided. A copy of report sent via email for signature.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: CEDARS ASSISTED LIVING, THE
FACILITY NUMBER: 197608267
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/04/2020
Section Cited

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Theft and Loss (i) Reports to the local law enforcement agency within 36 hours when the administrator of the facility has reason to believe resident property with a then current value of one hundred dollars ($100) or more has been stolen…
This requirement is not met as evidenced by:
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Based on interviews and records reviewed, the licensee did not comply with the section cited above, as the administrator did not follow the theft and loss procedures as required, which is a potential personal rights risk to residents in care.
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Type B
11/04/2020
Section Cited

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Reporting Requirement. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below…(A) Death of any resident from any cause regardless of where the death occurred…
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This requirement is not met as evidenced by: Based on interviews and record review, licensee did not comply with the above section by failing to submit SIR and death report as required, which is a potential health, safety and personal rights 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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: CEDARS ASSISTED LIVING, THE
FACILITY NUMBER: 197608267
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/04/2020
Section Cited

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Plan of Operation (a) Each facility shall have and maintain a current, written definitive plan of operation. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval.
This requirement is not met as evidenced by:
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Based on interviews and record review, licensee did not comply with the above section by failing to obtain approval from the Department prior to utilizing a modified admission agreement, which is a potential health, safety and personal rights 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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2020
LIC809 (FAS) - (06/04)
Page: 3 of 3