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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608267
Report Date: 06/21/2023
Date Signed: 06/21/2023 01:37:16 PM


Document Has Been Signed on 06/21/2023 01:37 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
N LA & CEN COA AC/SC, 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: 133DATE:
06/21/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Mary Jane ReyesTIME COMPLETED:
01:50 PM
NARRATIVE
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On 06/21/2023 Licensing Program Analyst (LPA) Evelin Rios conducted an announced Case Management - Deficiencies visit in conjunction with complaint control #31-AS-20230613163023. During physical plant tour at 11:06 a.m. while residents were being gathered for lunch in the dinning room, LPA observed resident#1(R1) restrained with an orange belt like strap that wrapped around R1's stomach and the back of the chair. R1 requested assistance from LPA stating they were unable to stand up. LPA immediately contacted the Resident Care Director Mary Jane Reyes who prompted staff #1(S1) to immediately remove the strap/restraint. Interview with S1 revealed strap/restraint is used to keep R1 from falling off chair. According to S1, R1 is able to move around the facility in their wheel chair freely but does not follow directions around meal time to stay seated while meals are being served. According to S1 the restraint allows staff to do other things and not worry about R1 having a fall. According to Mary she was unaware staff were using the restraint. According to Mary she confiscated the strap and will conduct an in-service meeting with staff about prohibiting the use of restraints.

Deficiency cited (refer to LIC809D) Exit interview conducted, a copy of this report and Appeal Rights provided.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2023
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 06/21/2023 01:37 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
N LA & CEN COA AC/SC, 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: 06/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/22/2023
Section Cited
CCR
87608(a)(1)

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(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.
(1) Postural supports shall be limited to appliances or devices such as braces, spring release trays, or soft ties, used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc. This requirement was not met as evidenced by:
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Staff immediately removed restraint from resident. The Resident Care Director will have an in-service meeting with staff about regulation cited. POC cleared on todays visit.
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Based on interview and record review, the licensee did not comply with the section cited above by using a strap to restrict resident's movement such as falling out a chair which poses an immediate health, safety or personal rights risk to persons 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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2023
LIC809 (FAS) - (06/04)
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