197610430-9-12-2025-31-AS-NMAN-DLUV43-20250925160542

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610430
Report Date: 08/08/2025
Date Signed: 09/12/2025 01:00:05 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
01/30/2025 and conducted by Evaluator Antonia Alvizar-Ettima

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20250130140733

FACILITY NAME:	MONTECEDRO		FACILITY NUMBER:	197610430
ADMINISTRATOR:	WEIDERT, DAVID		FACILITY TYPE:	741
ADDRESS:	2212 EL MOLINO AVE		TELEPHONE:	(626) 788-4900
CITY:	ALTADENA	STATE: CA	ZIP CODE:	91001
CAPACITY:	300	CENSUS: 189	DATE:	08/08/2025
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Robin Gordon, Interim Administrator;Ruzannz Sergeyev, Director Resident Health Services; Kohar Kelkelyan, Director Resident Services		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Facililty failed to follow proper evacuation procedures

INVESTIGATION FINDINGS:

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This is an amendment to the Licensing report previously issued to the facility on 08/08/2025.
Licensing Program Analyst (LPA) Antonia Alvizar Ettima and Regional Manager (RM) Angela Whittaker conducted an unannounced subsequent complaint visit to the facility to continue an investigation of the above allegation.

During the initial investigation that was conducted virtually on 02/06/2025 at 1:30pm, Licensing Program Manager (LPM) Naira Margaryan, and LPA interviewed former Executive Director (ED), Residents Care Director and Director of Health Care Services. During subsequent visit on 07/11/2025, LPM and LPA interviewed facility staff who worked on 01/07/2025 on various shifts. Interviews were conducted in person and over the phone, which included Administrative Personnel, Managers, Licensed Vocational Nurses (LVNs), Caregivers, Security Guard, Human Resources Personnel and Activities Director. During the subsequent visit on 07/11/2025 LPA and LPM gathered the following information from the interviews.
Cont. on LIC9099C

Substantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Antonia Alvizar-Ettima
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025

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-20250130140733

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: MONTECEDRO	FACILITY NUMBER: 197610430
	VISIT DATE: 08/08/2025

NARRATIVE

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Cont. from LIC 9099-C

They notified the ED that they had evacuated. At around 7:00am, after everyone arrived at the emergency

shelter, the facility staff completed roll call and noted that 2 residents were not at the Pasadena Convention
Center. Facility staff notified the Sheriff’s Department. They returned to the facility and conducted a sweep of the facility. This was when they located resident #1 (R1) in the hallway. While they were evacuating R1, Resident #2 (R2), was walking towards the facility from outside. R2 had no knowledge about the evacuations. They were coming back after walking their dog. Both residents were taken to the Pasadena Convention Center. No one was able to explain how R1 was left in their room and how R2 end up being outside of the facility walking their dog, it was not clear how long R2 was outside and where was R2, after ED ordered “Shelter in Place.”

Interviews revealed that an annual emergency disaster training was provided only to the administrative personnel and managers. On 01/07/2025 when the wind picked up in Altadena most administrative personnel and management left the facility and went home. They worked in the morning between 7:00am-5:00pm.

During the review of the facility’s Disaster Protocol Procedures, the LPM and LPA read that during an emergency, designated staff should remain at the facility physically. The designated staff was the ED (pg.1). If a disaster occurs all staff on shift are responsible for the residents. (pg. 4). The ED is responsible for notifying Community Care Licensing (CCL) of the disruption of services. ED is also responsible for arranging additional staff to report to the facility through the emergency recall list. During the initial visit, when the LPA requested the recall list from the ED, ED replied that there was no recall list available with staff’s names and phone numbers, and no staff was contacted to assist. The ED left the facility the night before and informed S1 to contact him should they need anything.

Based on the information revealed during interviews and records review, it was concluded that 2 residents were left behind due to the facility’s failure to follow facility emergency evacuation procedures. Therefore, the allegation is SUBSTANTATED at this time.

No health and safety issues were noted during this visit. Exit interview conducted.

Deficiency issued on 9099-D. Report signed and issued. Appeal rights delivered.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Antonia Alvizar-Ettima
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20250130140733

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: MONTECEDRO	FACILITY NUMBER: 197610430
	VISIT DATE: 08/08/2025

NARRATIVE

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Cont. from LIC 9099

On 01/07/2025 from 11:00pm-7:00am there were only 5 individuals working at the facility: the Building and Safety Manager Staff #1 (S1); one security guard Staff #2 (S2), two caregivers Staff #3 (S3) and Staff #4 (S4), and one LVN Staff #5 (S5). ED, who was assigned as the emergency contact per the facility’s emergency evacuation procedures, left the facility at approximately 10:30pm. At 11:30pm they called the facility and gave an order to S1 to “Shelter in Place”. The only person who had knowledge of facility emergency evacuation procedures and was on shift was S1 who was busy securing the building, preparing water hoses, checking generators, and other parameters.

Interviews also revealed that LVNs that work each shift were allegedly in charge of the facility operations in the absence of the Executive Director. However, the nurse working the night shift on 01/07/2025 and 01/08/2025, was not a facility staff. Due to staff shortages the facility brought in a nurse from an outside agency. The ED that was responsible for putting the emergency procedures into action did not inform the LVN of the emergency evacuation procedures, before they left the facility at 10:30pm. No additional instructions were given, and no arrangements were made to bring additional qualified staff who had knowledge of the facility evacuation procedures were put in place. Facility residents, except those who got the information from the news, were not notified about the high winds, possible power outage, or any other concerns. When the wind worsened and fires started in the area, the ED and other Executive members and managers were communicating via a group chat and were waiting to receive a mandatory evacuation order from the Sheriff Department. Interim, staff did not receive any instructions to walk through the facility, check the residents or bring them down to the assembly area to prepare in case an evacuation was needed. The individuals that had specific assigned emergency duties were not present in the facility and did not return to the facility until after 5:00am on the following day 01/08/2025.

On 01/08/2025 at approximately 3:00am after many attempts to contact the Sheriff’s Department, S1 and S2 were able to contact the Sheriff’s Department and requested assistance to evacuate the residents in care. In total, the Sheriffs provided 6 buses, and the facility had 2 buses to transport the residents to the Pasadena Convention Center. At approximately 5:30am the evacuation started, and residents and staff were transported to the Pasadena Convention Center.

Cont. on LIC9099-C

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Antonia Alvizar-Ettima
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025

LIC9099 (FAS) - (06/04)

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Citations on this Visit Report are Under Appeal!

Control Number 31-AS-20250130140733

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: MONTECEDRO	FACILITY NUMBER: 197610430
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/08/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Under Appeal Type A 08/11/2025 Section Cited HSC 1569.695(a)(7)(H)	1 2 3 4 5 6 7	Emergency Plans (a) … A residential care facility... shall have an emergency... plan that shall include, but not be limited to, ... the following: (7) Procedures that address, … the following: (H) Procedures for confirming the location of each resident during an emergency response.	1 2 3 4 5 6 7	Administrator agrees to provide information on subsequent resident and staff training in regard to emergency response protocols. Administrator will provide proof of completed training and content outlines. Documentation will be submitted by POC due date via email to CCLD.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by. The Licensee failed to confirm the location of 2 residents during an evacuation. This possess an immediate health and safety risk 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.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Antonia Alvizar-Ettima
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025

LIC9099 (FAS) - (06/04)

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