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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608267
Report Date: 01/25/2023
Date Signed: 01/25/2023 02:29:39 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
07/26/2022 and conducted by Evaluator Joscelyn Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20220726163227
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: 132DATE:
01/25/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Aris Vergara TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff did not clean resident's room while resident was in skilled nuring
Staff did not respond to resident's request for belongings
INVESTIGATION FINDINGS:
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On 01/25/22 Licensing Program Analyst (LPA) Joscelyn Martinez arrived at the facility to conduct a subsequent complaint visit investigtion. Upon arrival LPA met with administrator Aris Vergara and the purpose of the visit was explained.

Allegation: Staff did not clean resident's room while resident was in skilled nuring.

It is alleged that facility did not clean R1’s room during their stay at a skilled nursing facility. The Regional Office received pictures from a credible witness of R1’s room. One of the pictures contained spoiled milk inside R1’s refrigerator. On 08/02/22 LPA toured R1’s room and found spoiled food by the front door. Additionally LPA observed gnats around the food and R1’s clothing on the floor. According to interview conducted R1 had left the facility in November 2021 and was then discharged to a skilled nursing facility. R1 had not since return to Cedars Assisted Living. Based on observation this allegation is deemed Substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
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 4
Control Number 31-AS-20220726163227
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: 01/25/2023
NARRATIVE
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Allegation: Staff did not respond to resident's request for belongings

It is alleged that R1 had moved out from the facility and was not able to obtain their items from the facility. LPA conducted a telephonic interview with R1 in where they stated they had left the facility in November of 2021 to go to the hospital. After being discharged from the hospital R1 went to a skilled nursing facility. R1 stated that their caseworker was trying to schedule a date in where R1’s son could go to the facility to pick up their personal belongings, but a date was never arranged. R1 stated they are currently bedbound and not able to move their items unassisted. On 08/02/22 LPA conducted a walk through of R1’s room. Inside the room LPA observed R1’s belongings such as clothing, electric chair, mail, and other personal toiletries. Interview with S2 revealed that R1’s son called the facility to pick up R1’s belongings but never showed up. Interview with S3 revealed that the facility policy is to contact the resident’s representative or caseworker to arrange pick up. If the resident is unable to pick up their items Cedars can assist the resident in receiving their belongings. Due to R1’s belongings still being at the facility for about ten months after they left, this allegation is deemed Substantiated.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited.

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: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20220726163227
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: 01/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/27/2023
Section Cited
CCR
87303(a)
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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 was not met as evidenced by
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Licensee agreed to clear out R1's room and return items to R1. Proof of schedule date will be emailed to LPA.
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Based on observation, the facility did not clean R1's room during their stay at the skilled nursing facility. This poses an potential health and safety risk or personal rights to residents in care.
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Type B
01/27/2023
Section Cited
CCR
87468.1(a)
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87468.1 Personal Rights of Residents in All Facilities(a) (9)To have communications to the licensee from their representatives answered promptly and appropriately.

This requirement was not met as evidenced by

Based on interviews facility did not
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Licensee has agreed to communicate with R1 and arrange a date of scheduling for R1's item to be returned. Proof of schedule date will be emailed to LPA.
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communicate with R1's representative to provide a date to schedule a pick up for R1's belongings. This poses an potential health and safety risk or personal rights 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: 01/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
07/26/2022 and conducted by Evaluator Joscelyn Martinez
COMPLAINT CONTROL NUMBER: 31-AS-20220726163227

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: DATE:
01/25/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Aris Vergara TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff did not safeguard the resident's property
INVESTIGATION FINDINGS:
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On 01/25/22 Licensing Program Analyst (LPA) Joscelyn Martinez arrived at the facility to conduct a subsequent complaint visit investigtion. Upon arrival LPA met with administrator Aris Vergara and the purpose of the visit was explained.

Allegation: Staff did not safeguard the resident's property
It is alleged that staff did not safeguarded R1’s property while they were transferred to the hospital and skilled nursing facility. Interview with R1 revealed that their property were still at the facility and had not been returned to R1 after they moved out. R1 stated they had not reported any missing items while they resided at the facility. On 08/02/22 LPA toured R1’s room and observed R1’s belongings inside the room. R1 waived their right to fill in the Client/Residential Personal Property and Valuables (LIC 621). Copy of this documentation was obtained and reviewed. Due to R1 not reporting any missing items this allegation is deemed Unsubstantiated.
Exit interview conducted. Report signed and delivered.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
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 4