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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608267
Report Date: 01/11/2023
Date Signed: 01/11/2023 05:40:44 PM


Document Has Been Signed on 01/11/2023 05:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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, THEFACILITY NUMBER:
197608267
ADMINISTRATOR:ARISTOTLE B. VERGARAFACILITY TYPE:
740
ADDRESS:17300 ROSCOE BLVD.TELEPHONE:
(818) 344-2042
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY:175CENSUS: 121DATE:
01/11/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Aristotle Vergara TIME COMPLETED:
05:00 PM
NARRATIVE
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On 01/11/23 Licensing Program Analyst (LPA) Joscelyn Martinez arrived at the facility to conduct an unannounced complaint investigation visit. During the visit LPA met with administrator and the purpose of the visit was explained. LPA and administrator conducted a physical room tour of R1's room. During the physical tour, LPA observed a lunch bag in the corner of the room. LPA observed gnats flying around the lunch bag and upon further observation LPA observed spoiled liquid and food inside the lunch bag. LPA had S2 remove the lunch bag out of the room immediately. Further inspection of the room revealed more gnats around the walls and ceiling areas. Interview with staff revealed that R1 has been in the hospital as of December 23, 2022 and staff did not check the unzip lunch bag to see if R1 had left any food or liquid inside that could spoil. LPA informed administrator and S2 the pest needed to be removed and cleaned due to the room being a shared room. Based on observation and interviews deficiency has been cited on 809-D.

Exit interview conducted. Report signed and delivered. Appeal rights delivered.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/11/2023 05:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/13/2023
Section Cited

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87303(a) Maintenance and Operation-The facility shall be clean, safe, sanitary and in good repair at all times.
This requirement was not met as evidenced by:

During R1's room tour LPA observed numerous gnats inside the room. LPA observed a lunch bag with spoiled items
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Lunch bag was removed from the room during the visit. Administrator agreed to conduct a check inside residents room who are currently in the hospital or SNF to ensure residents did not leave unattended food that could spoil and attract pests. Facilty will remove gnats from the room.Documentation of this walk through is to be provided to LPA.
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that was not thrown out by staff when R1 was admitted to the hospital on 12/23/22. This poses a potential health and safety risk to residents in care.
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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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2023
LIC809 (FAS) - (06/04)
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