197608267-9-7-2022-31-AS-RRAZ-CK55DC-20221011195142

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 09/07/2022
Date Signed: 09/07/2022 01:33:57 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
08/18/2022 and conducted by Evaluator Wendell Smith

COMPLAINT CONTROL NUMBER: 31-AS-20220818174806

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:	01:35 PM

ALLEGATION(S):

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Expired food was left in resident's room.
Staff not disposing of resident's trash
Facility room is unkempt.
Facility room has foul odor

INVESTIGATION FINDINGS:

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Licensing Program Analyst(s) Wendell Smith and Joscelyn Martinez conducted an unannounced subsequent visit to finish investigation into the allegations above. LPA met with the administrator and explained the reason for this visit.
Initial visit was conducted on 8/25/22. During that visit interviews were conducted with staff and toured resident bedrooms. LPA also obtained copies of pertinent documents related to the allegations above.
Regarding the allegations above it is alleged that resident #1(R1) room #273 that there was expired food left in the room, that staff did not dispose of resident's trash, and that the room was unkempt and had a foul odor. During the course of the investigation LPA obtained pictures of room #273 which showed expired food and trash all over the room. Interviews with staff revealed that housekeeping was supposed to clean the room on once a week and that it was not done in room #273. Based on the information obtained through interviews and observation all four of these allegation are deemed Substantiated at this time. Deficiencies cited on LIC 9099 D. Appeal Rights explained. Exit Interview conducted.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
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-20220818174806

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: 09/07/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/14/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Facility will have room #273 deep cleaned and submit pictures. Staff will go to each room and see if any other rooms need to be deep cleaned.
	8 9 10 11 12 13 14	Based on interviews and observation room #273 was not clean, trash was all over the room along with expired food, and foul odor was observed in the room. This posed a potential health and safety risk to resident's 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: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022

LIC9099 (FAS) - (06/04)

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