197608267-6-30-2022-31-AS-NGID-CGZPF8-20220805111618

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 06/30/2022
Date Signed: 06/30/2022 10:50:05 AM

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
06/06/2022 and conducted by Evaluator Angela Panushkina

COMPLAINT CONTROL NUMBER: 31-AS-20220606091219

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: 116	DATE:	06/30/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Lourdes Kazdan, Resident Care Director		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff do not safeguard a resident's personal belongings
Facility has inadequate record keeping for a resident

INVESTIGATION FINDINGS:

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At 10:00am Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced subsequent complaint visit to deliver the finings for the above stated allegations. LPA met with Resident Care Director, Lourdes Kazdan, and explained the reason for the visit.

LPA conducted a physical plant walk through, at approximately 10:30am, to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. LPA did not observe any immediate health and safety issues during the visit.

An initial 10-day complaint visit conducted on 06/15/22. During that visit LPA Panushkina conducted interviews (between 9:45am – 2:50pm) with the Executive Director, Administrator, Resident Care Director, Wellness Coordinator, Maintenance Director, 3 out of 3 staff, 11 out of 11 residents and reviewed facility records. LPA also obtained copies of pertinent documents relevant to the investigation. In addition, on
Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022

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-20220606091219

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: 06/30/2022

NARRATIVE

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06/21/22, LPA conducted a collateral visit to Residence at Royal Bellingham facility where Resident #1 (R1) currently resides. LPA conducted an interview with the Administrator and obtained copies of pertinent documents relevant to the investigation. During that visit LPA was unable to interview R1 because R1 was hospitalized.

Allegations: Staff do not safeguard a resident's personal belongings

Facility has inadequate record keeping for a resident
Interview with an Executive Director (ED), Administrator, Residents Care Director and Wellness Coordinator, on 06/15/22, revealed that R1 moved to the above facility due to having a lot of personal belongings that required bigger space/room. LPA was informed that upon admission to the above facility, R1 refused to sign any documents, including Client/Resident Personal Property and Valuables (LIC621). Interviews with two (2) out of three (3) staff members revealed that once the resident reports a personal item missing or stolen, they immediately notify verbally and/or in writing, to their management to conduct an investigation. Two (2) out of three (3) staff members did not recall R1 reporting any missing items during their stay at the above facility. In addition, LPA was informed that all of the R1’s belongings were packed (in boxes), labeled and delivered to a new facility by a Maintenance Director on 02/23/22. Interview with a Maintenance Director revealed that the delivery of R1’s personal items was completed upon request. Interviews with eleven (11) out of eleven (11) residents revealed the following: one (1) out of eleven (11) residents waived the inventory of their personal belongings upon admission. Eight (8) out of eleven (11) residents’ belongings were inventoried by the above facility upon admission. One (1) out of eleven (11) residents did not have any personal belongings prior to admission due to their personal items being stolen from the motel they were staying at. One (1) out of eleven (11) residents stated: “No. No inventory was provided.” Eleven (11) out of eleven (11) residents informed LPA that through out their stay at the above facility none of their personal items have been missing/stolen.

During the collateral visit conducted by LPA on 06/21/22 to Residence at Royal Bellingham, interview with an Administrator, revealed that R1 refused to sign any documents upon admission. Administrator informed LPA that R1 always had random visitors come and go to their facility and R1 did not comply with the house rules. When LPA was granted access to R1’s apartment at the new facility, LPA observed several items that were claimed to be missing/stolen (some of them in damaged condition) being present.

Continue on LIC9099-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20220606091219

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: 06/30/2022

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	Based on the information obtained through interviews, review of documents and LPA observation the above two allegations deemed Unsubstantiated at this time. No deficiencies cited. Exit interview conducted and copy of this report emailed to the Administrator.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3