197608267-3-18-2023-31-AS-RRAZ-CQELSX-20230330090125

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 03/18/2023
Date Signed: 03/18/2023 04:21:06 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
11/18/2021 and conducted by Evaluator Angela Panushkina

COMPLAINT CONTROL NUMBER: 31-AS-20211118111719

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: 133	DATE:	03/18/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Aristotle Vergara, Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff wear their mask under their noses
Residents rooms are not in good condition

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced subsequent visit at this facility to investigate the above allegations. LPA met with the Administrator and explained the reason for the visit.

During the initial visit made on 11/23/21 by LPAs Panushkina and Stamp at 10:20am, LPAs conducted physical plant tour, at 10:30am LPA reviewed facility files and obtained copies of pertinent documents relevant to the investigation. At the time of initial visit at 11:20am, LPAs also conducted interview with ten (10) staff and twelve (12) residents.

Allegation: Staff wear their mask under their noses.

During the initial visit, while conducting interviews with Staff #1 (S1) at 10:00am, Staff #3 (S3) at 11:57am and Continue on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2023

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-20211118111719

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: 03/18/2023

NARRATIVE

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Staff #5 (S5) at 1:25pm, LPAs observed all three (3) staff members were not wearing their COVID masks appropriately. LPAs informed staff to put the mask up and use it properly. All three (3) staff members immediately complied and pulled their masks over the nose. Based on LPAs observation, during the visit made on 11/23/21, this allegation is deemed Substantiated.

Allegation: Residents rooms are not in good condition

During the initial visit, LPAs Panushkina and Stamp conducted a physical plant tour of the facility and observed a broken closet door at 11:25am. In addition, at 11:56am LPAs observed the bathroom vanity in one of the resident rooms was in a bad condition and dirty. At 12:58pm, LPAs observed a cut out in the wall behind the residents’ entrance door. During todays visit LPA Panushkina observed and confirmed that all previously mentioned issues have been resolved/fixed. Based on LPAs observation, during the visit made on 11/23/21, this allegation is deemed Substantiated.

Deficiency cited on LIC9099-D

Exit interview conducted, appeal rights explained and copy of this report signed and delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 6

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
11/18/2021 and conducted by Evaluator Angela Panushkina

COMPLAINT CONTROL NUMBER: 31-AS-20211118111719

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: 133	DATE:	03/18/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Aristotle Vergara, Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff left resident in the bathroom resulting in unexplained injury
Staff did not allow resident representative to document an injury
Staff did not provide incident report of unexplained injury
Staff do not assist resident with incontinence needs
Residents toilets not in good condition

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced subsequent visit at this facility to investigate the above allegations. LPA met with Executive Director and explained the reason for the visit.

During the initial visit made on 11/23/21 by LPAs Panushkina and Stamp at 10:20am, LPAs conducted physical plant tour, at 10:30am LPA reviewed facility files and obtained copies of pertinent documents relevant to the investigation. At the time of initial visit at 11:20am, LPAs also conducted interview with ten (10) staff and twelve (12) residents.

Allegation: Staff left resident in the bathroom resulting in unexplained injury

During the initial visit, LPA conducted an interview with the Resident Care Director and was informed that
Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 31-AS-20211118111719

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: 03/18/2023

NARRATIVE

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on 11/17/21, during the morning rounds in a Memory Care Unit, staff discovered R1 sitting on the bathroom floor. LPA was informed that although, R1 had an unwitnessed fall and sustained a minor injury, an immediate care was provided by the facility MedTech. Thus, there was no evidence of neglect/lack of supervision. Based on the information gathered, this allegation is deemed Unsubstantiated.

Allegation: Staff did not allow resident representative to document an injury

It was alleged that on 11/18/21, facility staff refused the Reporting Party (RP) to take pictures of R1 due to the incident that occurred on 11/17/21. To investigate this allegation, during the initial visit (made on 11/23/21) LPAs conducted an interview with the Resident Care Director (RCD) at 10:25am. Interview with RCD confirmed that on 11/18/21 RP visited the facility and was not allowed (by the facility staff) to take pictures of R1 without getting the consent from R1’s primary responsible party. Based on the information gathered, this allegation is deemed Unsubstantiated.

Allegation: Staff did not provide incident report of unexplained injury

It was alleged that on 11/18/21, facility staff would not provide Reporting Party with the incident report for R1. To investigate this allegation, on 11/23/21 LPA Panushkina reviewed all LIC624’s (Unusual Incident/Injury Report) submitted to the Regional Office (RO) from 11/16/2021 to 11/23/2021. Review of documents revealed that a total of nine (9) Incident Reports have been submitted to RO, regarding random residents, and LPA did not observe R1’s incident that occurred on or about 11/16/21 or 11/17/21. However, the facility provided R1’s Incident Report to LPA indicating that the form was filed and submitted to the Regional Office. Based on LPA record review and observation this allegation is deemed Unsubstantiated at this time.

Allegation: Staff do not assist resident with incontinence needs

It was alleged that R1 always smells of urine and his/her clothing is always soaked in urine. To investigate the allegation, during the initial visit conducted on 11/23/21 at 11:30am, LPAs Panushkina and Stamps made observations during a physical plant tour. LPAs did not experience any malodor and all observed residents were clean and well groomed. In addition, during the attempted interview with Resident #1 (R1) at 12:05pm,
Continue on LIC9099-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 31-AS-20211118111719

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: 03/18/2023

NARRATIVE

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LPAs observed R1’s clothes dried, clean and R1 appeared to be well groomed and looked and smelled fresh/clean. Finally, interviews with staff also revealed that residents are changed regularly and that they are not left soiled for an extended period. Based on observations and interviews, there is not enough information to verify the allegation, therefore, the allegation is Unsubstantiated at this time.

Allegation: Residents toilets not in good condition

To investigate this allegation, LPAs Panushkina and Stamp, during the initial visit conducted on 11/23/21, inspected three (3) resident rooms and observed all toilets were in good condition and were properly operating. In addition, during today’s visit (03/18/23), LPA Panushkina inspected an additional three (3) resident rooms between 1:25pm and 1:30pm and observed all bathroom toilets are in good and working condition. Based on LPA record review and observation this allegation is deemed Unsubstantiated.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 31-AS-20211118111719

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: 03/18/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/24/2023 Section Cited CCR 87470(c)(1)(F)	1 2 3 4 5 6 7	87470(c) Infection Control Requirements shall be developed by the licensee... (1) The Infection Control Plan shall include: (F) Staff shall demonstrate knowledge... appropriate to the job assigned and... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator agreed to provide in house training with all staff regarding Infection Control Requirements and COVID Protocol. A written statement signed by all staff regarding such training shall be emailed to LPA by POC date.
	8 9 10 11 12 13 14	Based on LPAs observation during a previous visit conducted on 11/23/21, Licensee did not comply with the section cited above by having three (3) staff members at the facility not wearing COVID masks appropriately, which poses/posed a potential Health and Safety and Personal Rights risk to persons in care.	8 9 10 11 12 13 14
Type B 03/24/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/adminsitrator shall review California Code of Regulations Title 22 section 87303 and submit a written plan to ensure that the facility is in good repair at all times.
	8 9 10 11 12 13 14	Based on interviews, record review and observations, the licensee did not comply with the section cited above as the closet doors, bathroom vanity and the wall in three (3) rantom residnet rooms were left in disrepair while the rooms were occupied by a residents which poses/posed a potential Health, Safety, or Personal Rights risk to residents in care.	8 9 10 11 12 13 14

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: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2023

LIC9099 (FAS) - (06/04)

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