197608267-4-6-2022-31-AS-NMAN-CHUKD4-20220901074808

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 04/06/2022
Date Signed: 04/06/2022 02:37:55 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
01/07/2022 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20220107145747

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: 113	DATE:	04/06/2022
		UNANNOUNCED	TIME BEGAN:	08:31 AM
MET WITH:	Mary Jane Reyes - Wellness Coordinator		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Resident was touched inappropriately by another resident while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegation. LPA met with staff Mary Jane Reyes and explained the reason for the visit.

LPA conducted physical plant tour at 9:00 AM, requested copy of facility documents relevant to the investigation at 9:30 AM and interviewed resident and staff between 9:45 AM to 1:00 PM.

It was alleged that Resident #1 (R1) was visited by another resident on R1's room and touched R1's face. LPA's interview with R1 on 01/13/22 at 11:00 AM, revealed that R1 was not able to identify the resident who supposedly touched R1 and when the supposed incidents occurred. Resident #2 (R2) denied having been to R1's or any other resident's room nor touched anyone in the facility when interviewed by LPA on 01/13/22 at around 11:30 AM. (continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022

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-20220107145747

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: 04/06/2022

NARRATIVE

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(continued from LIC 9099)

LPA's interview today with Staff #1 (S1) at around 12:30 PM, revealed that S1 did not see R2 touched R1 and only saw R2 by the door of R1's room and not actually inside the room.

Based on the information gathered during this and prior visit, there is insufficient information to support the allegation and therefore deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022

LIC9099 (FAS) - (06/04)

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