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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 10/25/2021
Date Signed: 10/27/2021 01:04:16 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
10/20/2021 and conducted by Evaluator Joscelyn Martinez
COMPLAINT CONTROL NUMBER: 31-AS-20211020122325
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 does not have activities for residents in care
Residents are not provided adequate meals
INVESTIGATION FINDINGS:
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Licensing Program Analyst(s) (LPA) Jocelyn Martinez and Wendell Smith conducted an unannounced complaint visit to investigate the allegations above. LPA's met with the administrator and explained the reason for this visit.

Facility does not have activities for residents in care
LPA's conducted interviews with the administrator and facility staff from approximately 9:45-10am. LPA's conducted interviews with residents from 10-11:30am. Interviews revealed that the facility does not have an activity director at this time and that the facility has not been providing activities for residents for the past few months. Based on the information obtained through interviews this allegation is deemed Substantiated at this time. Deficiency cited on LIC 9099 D.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
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 5
Control Number 31-AS-20211020122325
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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Residents are not provided adequate meals
It is alleged that residents are not provided food of good quality and is not cooked properly. LPA's conducted interviews with residents from 10am-11:30am. Interviews reveal that the majority of residents are not happy with the food quality. They complained that the food was hard, overcooked, and bland. LPA conducted a physical plant walk through of the kitchen area to observe the food supply. Based on the information obtained through interviews this allegation is deemed Substantiated. Deficiency cited on LIC 9099 D.

Exit Interview conducted. Appeal Rights explained. Copy of report emailed.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
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 5
Control Number 31-AS-20211020122325
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
10/29/2021
Section Cited
CCR
87219(a)
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Planned Activities-Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities.
This requirement was not met as evidenced:
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Administrator stated an activities calendar and will send a copy of the activities calendar to LPA by poc due date.
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Based on interviews conducted facility has not had any planned activities for a few months which poses a personal rights risk to residents in care.
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Type B
10/29/2021
Section Cited
CCR
87219(f)
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Planned Activities-In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities, and shall be given such staff assistance as necessary in order for all residents to participate in accordance with their interests and abilities. This requirement is not met
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Administrator has stated they have hired an activities director. Administrator will send proof of hire to LPA by poc due date.
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as evidenced by: Based on interviews conducted the facility has not had an activity director for over a year.
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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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
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 5
Control Number 31-AS-20211020122325
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
10/29/2021
Section Cited
CCR
87555(b)(8)
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General Food Service Requirements-All food shall be of good quality.
This requirement was not met as evidenced by:
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Administrator stated he will have a meeting with the resident council and with the facility chef to discuss menu and food choices. Self certification will be sent to LPA when this is completed.
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Based on interviews conducted it appears the food served is not of good quality which is 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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
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: 5 of 5