197608267-1-11-2023-31-AS-NGID-CND2D3-20230123161740

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 01/11/2023
Date Signed: 01/11/2023 05:42:34 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
01/06/2023 and conducted by Evaluator Joscelyn Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20230106145004

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: 121	DATE:	01/11/2023
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Aristotle Vergara		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident does not have access to appliances to prepare meals

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 01/11/23 Licensing Program Analyst (LPA) Joscelyn Martinez arrived at the facility to conduct an unannounced complaint investigation visit. Upon arrival LPA met with administrator and the purpose of the visit was explained.

Allegation 1: Resident does not have access to appliances to prepare meals

It is alleged that R1 has requested a refrigerator and microwave to be placed inside R1's room. Interview with R1 revealed that R1 is under the Assisted Living Waiver (ALW) program and was informed by a credible source that residents have the right to a refrigerator and microwave for their room. R1 stated they have requested these items from staff for about two (2) months but has not received them. Interviews with three (3) out of three (3) staff stated they have not received a request for these items from R1. LPA reviewed R1's Assisted Living Waiver Amenity Form (DHCS 0060). Document reviewed revealed R1 did not waive their right to a refrigerator nor microwave. R1 has lived at the facility as of October 03, 2022 and has not received the requested items.

Substantiated

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: 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.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 31-AS-20230106145004

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: 01/11/2023

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	LPA conducted a tour of R1's room and did not observe a refrigerator nor microwave. Based on interviews, observation, and document review, this allegation is deemed Substantiated. Exit interview conducted. Deficiency issued on 9099-D. Report signed and delivered. Appeal rights delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 31-AS-20230106145004

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: 01/11/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/13/2023 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1(a)(2) Personal Rights of Residents in All Facilities to be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on interview, observation, and document	1 2 3 4 5 6 7	Facility is to prove a refrigerator and microwave to R1 under the ALW program. Administrator will send proof of purchase/placement of items for R1 to LPA via email.
	8 9 10 11 12 13 14	review, R1 is under the ALW program in where residents have the right to request a refrigerator and microwave to be placed in their room. Facility did not provide requested items. This poses an potential health and safety risk or personal rights 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: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
01/06/2023 and conducted by Evaluator Joscelyn Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20230106145004

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:	DATE:	01/11/2023
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Aristotle Vergara		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility only has hot water (no access to cold water)
Facility toilet is in disrepair

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 01/11/23 Licensing Program Analyst (LPA) Joscelyn Martinez arrived at the facility to conduct an unannounced complaint investigation visit. Upon arrival LPA met with administrator and the purpose of the visit was explained.

Allegation: Facility only has hot water (no access to cold water)

It is alleged that R1 does not have cold water in their bathroom. To investigate this allegation LPA conducted a physical tour of R1's room and bathroom. LPA measured the hot and cold water temperature inside R1's bathroom. Hot water measured at 113.3 F and cold water measured at 54.6 degrees F. LPA conducted interview with facility maintenance director (S3). Interview revealed that S3 has not received a complaint about R1 not having cold water therefore S3 has not corrected any issues with the water. LPA interviewed R1's roommate (R2). Interview with R2 revealed they have not had any issues with not having cold water. R2 stated they have hot and cold water.

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: 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.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 31-AS-20230106145004

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: 01/11/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Based on interviews and observation, this allegation is deemed Unsubstantiated.

Allegation: Facility toilet is in disrepair

It is alleged that the toilet in R1's bathroom is in disrepair. LPA conducted a tour of R1's room and bathroom with S3 and S1. LPA had S3 flush the toilet and LPA observed the toilet functioning. Interview with S3 and S1 revealed they have not received any request from R1 that the toilet was in disrepair nor has S3 needed to repair to toilet. Interview with R1's roommate, (R2) revealed that they have not had any issues with the toilet being in disrepair. Based on interviews and observation, 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: 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

LIC9099 (FAS) - (06/04)

Page: 5 of 5