197608267-8-16-2022-31-AS-MVAO-CHKUQM-20220823154721

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 08/16/2022
Date Signed: 08/16/2022 02:56:33 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
01/29/2021 and conducted by Evaluator Michael Cava

COMPLAINT CONTROL NUMBER: 31-AS-20210129162251

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: 124	DATE:	08/16/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Aristotle Vergara, Mary Jane Reyes		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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9

Facility has roaches

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Michael Cava, conducted a subsequent complaint visit to the facility to conclude the investigation regarding the above allegation. The 10 day visit was made by LPA Alex Pitz on 02/03/21, followed by a subsequent visit made on 02/10/22. It is being alleged that roaches were seen in resident's bedroom and dresser drawer. During the course of LPA Pitz's investigation on 02/10/22, ten (10) residents were interviewed to see if they've experienced or observed roaches during their stay at the facility. Nine (9) of the ten residents confirmed that they've experience and observed rats and roaches in their rooms or common areas of the facility. In addition to interviews, LPA Pitz obtained copies of service reports from a pest control company, indicating service was needed for roaches and rodents.

Based on the information obtained, there was sufficient evidence to corroborate the allegation of faciilty having roaches. Therefore, the investigation is substantiated. Citation issued on the 9099D.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022

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-20210129162251

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: 08/16/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/16/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. This requirement has not been met as evidenced by: interviews with 10 residents made on 02/10/22. Nine (9) out of these ten residents confirmed of experiencing or observing roaches in their room or common	1 2 3 4 5 6 7	Copies of invoice and statments from pest control company as proof of service for roacheds and rodents was obtained during the visit. No further corrections needed at this time.
	8 9 10 11 12 13 14	areas of the facility. This is an immediate health and safety risk to the residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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
01/29/2021 and conducted by Evaluator Michael Cava

COMPLAINT CONTROL NUMBER: 31-AS-20210129162251

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: 124	DATE:	08/16/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Aristotle Vergara, Mary Jane Reyes		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

1
2
3
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5
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7
8
9

Staff are not meeting residents needs

INVESTIGATION FINDINGS:

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2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA), Michael Cava, conducted a subsequent complaint visit to the facility to conclude the investigation regarding the above allegation. The 10 day visit was made by LPA Alex Pitz on 02/03/21, followed by a subsequent visit made on 02/10/22. It is being alleged that staff is not providing assistance with resident showers. During the course of the investigation, interviews and record reviews were made.
Although Resident 1 (R1) is no longer at this facility, per staff and administrator, resident was provided assistance with showers two times per week. Review of R1's Needs and Services plan reveal that R1 needs assistance with their daily living. The objective is to maintain independence and assist as needed. In addition, interviews with random residents made, of which none of these residents expressed any complaints of not haveing their needs and/or shower assistance not being made. Based on the information obtained, there was insufficient evidence to corroborate the allegation of staff not meeting resident needs. Therefore, the investigation is deemed Unsubstantiated at this time.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022

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

LIC9099 (FAS) - (06/04)

Page: 3 of 3