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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 12/07/2021
Date Signed: 12/07/2021 02:58:08 PM

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
11/16/2021 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20211116121503
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: 108DATE:
12/07/2021
UNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Aristotle Vergara - AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Resident's needs are not being met while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent visit to this facility to further investigate the above allegation. LPA met with Aristotle Vergara and explained the reason for the visit.

LPA conducted physical plant tour at 9:20 AM, requested copies of facility documents relevant to the investigation at 9:40 AM and interviewed staff and resident at 10:00 AM. Resident's needs are not being met while in care, it was alleged that R1's needs is not being met. LPA's interview with R1 on 11/18/21 at around 10:30 AM and today at 10:19 AM, revealed that R1 needed more medical care and would like to transfer to a Skilled Nursing Facility (SNF). LPA's interview R1's case worker on 11/18/21 at around 12:00 PM, however, revealed that R1 did not have proper medical insurance and was not eligible for a long term stay at SNF as R1 did not have an eligible diagnosis. Further interview with R1 today at 10:19 AM also revealed that R1 is being provided sufficient non-medical care at the facility.

(continued to LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021
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 2
Control Number 31-AS-20211116121503
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: 12/07/2021
NARRATIVE
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(continued from LIC 9099)

LPA's interview with staff today at 11:21 AM also confirmed that R1 has a home health services company attending to R1's medical needs and is being checked by the facility staff regularly and as needed as R1 has a call pendant and called the facility reception by phone whenever R1 needed assistance

Based on the information gathered during this and prior visit, the allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2