197608267-10-6-2022-31-AS-RRAZ-CKCP4T-20221019105936

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 10/06/2022
Date Signed: 10/06/2022 02:06:05 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
07/07/2022 and conducted by Evaluator Joscelyn Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20220707133912

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: 128	DATE:	10/06/2022
		UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Aris Vergara		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

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Resident sustained multiple pressure injuries while in care

INVESTIGATION FINDINGS:

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On 10/06/22 Licensing Program Analyst (LPA) Joscelyn Martinez conducted a subsequent complaint visit for the purpose of issuing the completed investigative report conducted by CCL’s Investigative Branch (IB). On 07/07/22, a complaint was received by the Woodland Hills Adult and Senior Care Regional Office. The complaint was refereed to the Community Care Licensing Division’s Investigation Branch. The complaint was accepted by CCL IB and assigned to investigator Douglas Real. LPA Martinez met with Administrator Aris Vergara and the purpose of the visit was explained.

On 07/08/22 LPA Smith conducted an unannounced visit and collected relevant documents pertaining to the allegation.

Allegation: Resident sustained multiple pressure injuries while in care
It is alleged that Resident #1(R1) sustained multiple pressure injuries while in care of the facility. On 07/04/22 R1 went out for a walk outside the facility and had a fall.

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: 10/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022

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-20220707133912

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: 10/06/2022

NARRATIVE

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On 07/05/22 R1 was in pain due to the fall and paramedics were called to transfer R1 to the hospital. This fall and hospitalization was reported to CCL on 07/09/22. While hospitalized doctors observed wounds on R1’s legs and feet and alleged the wounds were obtained during R1’s stay at the facility.

On 08/24/22 Investigator Real conducted a visit at the facility to interview staff, residents and collected documents pertaining to the investigation. Documentation review and interviews determined that R1 moved into the facility on 06/30/22 from a skilled nursing home. R1 already had wounds on their legs and feet prior to residing at Cedars Assisted Living. According to interviews R1 was receiving home health wound care at the facility and was assessed by a nurse prior to the fall that occurred on 07/04/22. On 07/05/22 R1 was admitted to the hospital due to pain obtained during the fall on 07/04/22. Doctors observed the wounds and reported their observation to the Department. According to interviews by staff, R1 and R1’s family, these wounds were not obtained during R1’s stay at the facility.

Therefore, based on the information gathered during this investigation, “Resident sustained multiple pressure injuries while in care”, is deemed Unsubstantiated.

No deficiencies cited. Exit interview conducted. Report signed and delivered. Appeals right delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022

LIC9099 (FAS) - (06/04)

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