197608267-9-7-2022-31-AS-RRAZ-CJG3H7-20220920181526

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 09/07/2022
Date Signed: 09/07/2022 01:47:43 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
01/25/2022 and conducted by Evaluator Joscelyn Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20220125084224

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: 114	DATE:	09/07/2022
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Aristotle Vergara		TIME COMPLETED:	01:50 PM

ALLEGATION(S):

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Lack of supervision resulting in resident suffering a fall.
Staff did not ensure resident was provided with appropriate footwear

INVESTIGATION FINDINGS:

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On 09/07/22 Licensing Program Analysts (LPAs) Joscelyn Martinez and Wendell Smith conducted a subsequent complaint visit. Upon arrival LPA met with staff and later met with Administrator Aris Vergara.
On 02/02/22 LPA Martinez conducted the initial complaint visit. During that visit interviews were conducted with staff and administrator. LPA also collected relevant documentation pertaining to the complaint investigation. On 05/12/22 LPA Martinez conducted a collateral visit to interview R1 at a rehab facility.

Allegation #1 Lack of supervision resulting in resident suffering a fall
It is alleged that R1 suffered a fall due to lack of supervision on 10/11/2021. During the course of the investigation, LPA conducted interviews with administrator, facility staff, R1, and staff at the rehab facility R1 is residing in. LPA obtained and review documents such as R1 physician report, R1’s Needs and Service Plan, R1’s Serious Incident Report, and R1’s Care Plan. On 04/18/22 LPA subpoena R1’s medical records dated from 09/01/21 to 01/25/22.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022

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-20220125084224

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: 09/07/2022

NARRATIVE

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According to the documents R1 did sustain a fall in their room, but it was not due to facility’s negligence. Staff observed R1 on the floor in their room during a routine afternoon shift. Facility immediately contacted paramedics to transport R1 to the hospital for an assessment. Based on the information obtained through interviews and documentation review this allegation is deemed Unsubstantiated.

Allegation #2 Staff did not ensure resident was provided with appropriate footwear.

It is alleged that facility did not provide R1 appropriate footwear. To investigate this allegation LPA Martinez conducted interviews with staff and administrator. On 04/18/22 LPA obtained and reviewed documents such as R1 physician report, R1’s Needs and Service Plan, R1’s Serious Incident Report, and R1’s Care Plan. On 05/12/22 LPA Martinez conducted a collateral visit to interview R1 at the rehab facility that R1 is residing in. Interview with S3 revealed that R1’s only request for footwear were non-slip socks. LPA obtained receipt of purchase for the non-slip socks that were provided to R1. Document review revealed that R1 did not have any physician note for any type of special footwear to be worn. Interview with R1 revealed that it was unclear what type of footwear R1 needed to wear. Based on interviews and documentation review this allegation is deemed Unsubstantiated.

Exit interview conducted. Report signed and delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022

LIC9099 (FAS) - (06/04)

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