197608267-5-13-2023-31-AS-TAGD-CWBUZ8-20231005160106

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 05/13/2023
Date Signed: 05/13/2023 03:28:35 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
04/15/2022 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20220415171745

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: 138	DATE:	05/13/2023
		UNANNOUNCED	TIME BEGAN:	08:42 AM
MET WITH:	Todd Anderson - Manager on Duty		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff mimic's resident
Resident's call button is inaccessible
Staff not logging resident's inventory list.
Facility not providing resident's inventory list to ombudsman representative.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent visit at this facility to further investigate the above allegations. LPA met with Manager on Duty Todd Anderson and explained the reason for the visit.

LPA conducted physical plant tour at 9:00 AM, requested copies of facility documents relevant to the investigation at 9:22 AM. Interviewed staff between 10:00 AM to 1:00 PM and reviewed records between 1:00 PM to 2:45 PM. Regarding the allegation that facility staff mimics resident, it was alleged that staff from second floor mimics R1. LPA's interview with three (3) staff today between 10:00 AM to 1:00 PM revealed that all three (3) staff who serviced Resident #1 (R1) when R1 was still here and no one among them mimicked R1 nor they witnessed anyone mimicking R1.

(continued to LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2023

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-20220415171745

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CEDARS ASSISTED LIVING, THE	FACILITY NUMBER: 197608267
	VISIT DATE: 05/13/2023

NARRATIVE

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(continued from LIC 9099)

Regarding the allegation that Resident's call button was inaccessible, it was alleged that R1's call button was being moved by the staff, LPA's interview with three (3) staff today between 10:00 AM to 1:00 PM revealed that all three (3) staff serviced Resident #1 (R1) when R1 was still here that no one among them moved R1's call button as R1 tied it to own bed rails and always beside R1. LPA's observation during visit on 01/05/22 on a different complaint for R1, LPA's observed that the call button was tied on R1's bed rail beside R1.

Regarding the allegation that the staff not logging resident's inventory list, it was alleged that the staff did not log personal belongings such as oil, soaps, Bengay, vitamins. LPA's record review today between 1:00 PM to 2:45 PM revealed that client/personal property and valuables (LIC 621) duly signed by R1 did not contain any personal belongings item. LPA's interview with the administrator today revealed that during their meeting with R1 and R1's family member on 03/16/22, R1 and family member agreed to create an inventory of all the personal belongings of R1 and turn it over to the facility but when the private caregiver came to the facility to do the inventory, R1 refused.

Regarding the allegation that the is Facility not providing resident's inventory list to ombudsman representative, it was alleged that the Ombudsman requested the R1's inventory log and has not received it. LPA's interview with the administrator today revealed that during their meeting with R1 and R1's family member on 03/16/22, R1 and family member agreed to create an inventory of all the personal belongings of R1 and turn it over to the facility but when the private caregiver came to the facility to do the inventory, R1 refused and therefore no inventory list was created to provide to the Ombudsman at that time.

Based on the information gathered during this and prior visit, there is insufficient evidence to support the allegations and therefore deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2023

LIC9099 (FAS) - (06/04)

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