197608267-10-28-2020-31-AS-JAPL-BUVQH2-20201030121025

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 10/28/2020
Date Signed: 10/28/2020 03:32:11 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/05/2020 and conducted by Evaluator Ashley Smith

COMPLAINT CONTROL NUMBER: 31-AS-20200605155956

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: 120	DATE:	10/28/2020
		UNANNOUNCED	TIME BEGAN:	02:55 PM
MET WITH:	Aris Vergara		TIME COMPLETED:	03:05 PM

ALLEGATION(S):

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Resident#1(R1) is not receiving medication

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Smith conducted a subsequent complaint to the above facility. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted virtually via FaceTime with Aris Vergara. The purpose of the virtual visit is to deliver findings an investigation initiated and conducted by LPA Amin.

LPA Amin interviewed the administrator on 6/11/20 at 1:10 pm and R1's case manager on 6/11/20 at 2:25 pm. LPA Amin spoke with Wellness Coordinator on 6/15/20 at 10:42 am and R1's physician on 7/01/20 at 12:08 pm. On 6/10/20 at 4:20 pm, LPA Amin spoke with the resident#1 (R1). LPA Amin requested and received R1’s physician report, hospital records, and R1's doctor's note with the list of the medications and staff notes. The records were reviewed on 6/30/20 at 9:52 am.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2020

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-20200605155956

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: CEDARS ASSISTED LIVING, THE	FACILITY NUMBER: 197608267
	VISIT DATE: 10/28/2020

NARRATIVE

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It is alleged that facility staff are managing and securing the medication for Resident#1 (R1), who is capable of managing their own medications. At the time of the allegation, R1 did not have access to their medications. Based on the information obtained during the investigation, on 10/26/2019, R1 was transferred to the hospital due to an incident regarding mismanagement of their medication. On the same day, the EMT returned R1 to the facility and noticed that the medications in R1's room were not secured, and then questioned staff about the medication management. After discussing the issue with the administrator, the facility staff removed all the medication from R1's room. R1 was made aware of it and did not argue about it at that time. Moreover, based on the interview with the R1's case manager, they were aware of the situation and agreed with the facility's decision for the health and safety of R1. However, R1's physician was not informed. The facility does not have a written order from R1’s physician to take over the medication management for R1. R1's Physician’s Report dated 05/22/20 indicated that R1 is able to store and administer their own medications. The Emergency Room visit report does not indicate anything about R1’s capability to store the medication or the lack thereof. On 5/26/20, the facility received a written letter from R1's primary care indicating that R1 is able to manage their own medications. As a result, the staff gave the medications back to R1 to manage.

Based on the interview with the R1’s primary care physician, the physician is not aware of any incident of mismanagement of medication by R1. R1’s physician stated that R1 is alert, orientated, and is capable of storing and administering their own medication. R1 is aware of all the medications he/she takes.

Information obtained during this investigation revealed, although facility staff were looking out for R1's health and safety after R1 came back from the hospital, they did not have written order from a medical professional to take over the medication management from 10/26/19 to 5/26/2020. Therefore, the allegation, "Resident#1(R1) is not receiving medication" is Substantiated at this time.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D). Exit interview conducted. Appeal rights provided. A copy of report sent via email for signature.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2020

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20200605155956

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: CEDARS ASSISTED LIVING, THE	FACILITY NUMBER: 197608267
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/28/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/30/2020 Section Cited CCR 87463(b)	1 2 3 4 5 6 7	87463(b) Reappraisals (b) The licensee shall immediately bring any such changes to the attention of the resident's physician and his family or responsible person. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator has agreed to do the following: 1. Review Regulation 87463 and submit a Plan of Action detailing how the facility will maintain communication with pertinent parties regarding resident changes. Submit the Plan of Action by 10/30/2020.
	8 9 10 11 12 13 14	Based on the record review and interviews, the licensee did not comply with the section cited above, as staff did not inform R1's physician about R1's ER visit on 10/26/19 and changes in R1's ability to manage medication, which poses an immediate health and safety risk to 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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2020

LIC9099 (FAS) - (06/04)

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