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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608318
Report Date: 10/15/2024
Date Signed: 10/15/2024 02:28:09 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.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
10/08/2024 and conducted by Evaluator Tuesday Cabiness
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20241008144738
FACILITY NAME:CEDARCREEK VILLAFACILITY NUMBER:
197608318
ADMINISTRATOR:RICHARD K. GORDONFACILITY TYPE:
740
ADDRESS:20237 CEDARCREEKTELEPHONE:
(818) 269-2230
CITY:SANTA CLARITASTATE: CAZIP CODE:
91351
CAPACITY:6CENSUS: 5DATE:
10/15/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Angel Gomez & Dr. Richard GordonTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Personal Rights: Staff asked residents to switch doctors and use the facility’s Administrator as their hospice doctor.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tuesday Cabiness arrived to the facility to conduct the initial investigation. LPA met with House Manager Angel Gomez and Dr. Richard Gordon and informed them the reason of the visit. The following was determined:

It was alleged, staff asked residents to switch doctors and use the facility’s Administrator as their hospice doctor. On 10/14/2024 through 10/15/2024, ranging from 10am 245pm, LPA conducted interviews and reviewed resident records. From the information obtained, interviews revealed that staff have asked on several occasions for residents to change medical insurance from Kaiser, and make the Administrator, who is a medical physician, their primary doctor. According to regulations, residents have the right to select their own health care provider, without interference from staff trying to make them switch to the Administrator as their doctor. LPA determined it was a personal right violation, and it poses a potential health and safety risk to residents in care. Therefore, based on interviews, the allegation is Substantiated at this time.
Citation issued, appeal rights, exit interview and copy of report provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
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 3
Control Number 31-AS-20241008144738
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: CEDARCREEK VILLA
FACILITY NUMBER: 197608318
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/18/2024
Section Cited
CCR
87468.2(a)(18)
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Additional Personal Rights of Residents in Privately Operated Facilities. (a)...residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (18)To select their own physicians, pharmacies, privately paid personal assistants, hospice agency, and
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The Administrator has AGREED to put in writing, 'that I or my staff will not provide any medical information or opinions to any of my resident". POC cleared during visit, document was emailed to LPA.
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and health care providers...This requirement was not met, evidenced by, during interviews it was reported to LPA that staff have asked residents to switch there doctor to Dr. Gordon, who is the Administrator. This is a personal rights issue, because residents have the right to choose. This is a potential health and safety risk 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.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
10/08/2024 and conducted by Evaluator Tuesday Cabiness
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20241008144738

FACILITY NAME:CEDARCREEK VILLAFACILITY NUMBER:
197608318
ADMINISTRATOR:RICHARD K. GORDONFACILITY TYPE:
740
ADDRESS:20237 CEDARCREEKTELEPHONE:
(818) 269-2230
CITY:SANTA CLARITASTATE: CAZIP CODE:
91351
CAPACITY:6CENSUS: 5DATE:
10/15/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Angel Gomez & Dr. Richard GordonTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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9
Staff illegally evicted resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tuesday Cabiness arrived to the facility to conduct the initial investigation. LPA met with House Manager Angel Gomez and Dr. Richard Gordon and informed them the reason of the visit. The following was determined:

It was alleged staff illegally evicted resident. On 10/14/2024 through 10/15/2024, ranging from 10am 245pm, LPA conducted interviews and reviewed resident records. From the information obtained, resident #1 (R1) was discharged from the hospital after having surgery. (R1) was sent back to the hospital, for further treatment. Although it was reported to LPA staff returned (R1) because (R1) refused to switch from Kaiser to the Administrator as their hospice doctor. LPA determined, (R1) was discharged from the hospital after surgery, and staff conducted a physical assessment and observed (R1)’s surgery wound was still open and needed more treatment. Therefore, (R1) was sent back to the hospital. (R1) is currently in a skilled nursing facility and will not be returning to the facility, because of (R1)’s personal choice. Staff reported to LPA that the room is still available if (R1) returns. Therefore, based on interviews the allegation is Unsubstantiated at this time. Exit interview and copy of report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3