197609090-5-8-2024-31-AS-NMAN-D93SBG-20240913134354

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609090
Report Date: 05/08/2024
Date Signed: 05/08/2024 03:52:17 PM

Unsubstantiated

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
05/03/2024 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20240503164134

FACILITY NAME:	CYPRESS RESIDENCE II		FACILITY NUMBER:	197609090
ADMINISTRATOR:	MONJE-DU, CHERY B		FACILITY TYPE:	740
ADDRESS:	25459 VIA IMPRESO		TELEPHONE:	(661) 670-8949
CITY:	VALENCIA	STATE: CA	ZIP CODE:	91355
CAPACITY:	6	CENSUS: 4	DATE:	05/08/2024
		UNANNOUNCED	TIME BEGAN:	11:35 AM
MET WITH:	Ray Sarmiento		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff did not ensure resident was adequately fed.
Staff did not prevent resident from harming other residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Abeye Duguma conducted an initial complaint visit to the facility to investigate the above allegation. LPA met with administrator, Chery Monje-du, and explained the reason for the visit.

--- Staff did not ensure resident was adequately fed.

It was alleged that staff are not feeding residents resulting in malnourishment and dehydration. To investigate the allegation, on 05/08/2024, LPA conducted a physical plant tour at around 11:30 AM, interviewed three (03) staff from around 12:30 PM to 1:30 PM and interviewed two (02) out of four (04) residents from around 1:30 PM to 2:15 PM. During the physical plant tour, LPA observed facility staff preparing and serving meals. LPA also observed more than seven (07) days perishable and two (02) days non-perishable foods.
(CONT. on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024

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-20240503164134

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: CYPRESS RESIDENCE II	FACILITY NUMBER: 197609090
	VISIT DATE: 05/08/2024

NARRATIVE

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During interviews with staff, all staff stated that residents are fed three (03) meals a day and offer snacks at least twice a day. During interviews with residents, two (02) out of four (04) residents stated that facility feeds them very well, offer three (03) meals a day and snacks. LPA was unable to interview the remaining two (02) residents.

Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

--- Staff did not prevent resident from harming other residents.

It was alleged that Resident #1 (R1) was being verbally and physically abused by other residents. To investigate the allegation, on 05/08/2024, LPA conducted a physical plant tour at around 11:30 AM, interviewed three (03) staff from around 12:30 PM to 1:30 PM and interviewed two (02) out of four (04) residents from around 1:30 PM to 2:15 PM. During the physical plant tour, LPA did not observe any signs of abuse and all residents were clean and well groomed. During interviews with staff, all staff stated they have never physically or verbally abused any residents or allowed residents to abuse other residents. During interviews with residents, two (02) out of four (04) residents stated staff have never physically or verbally harmed them and that they are all very kind, gentle and treat them with dignity and respect. Residents also added they have never been physically or verbally abused by other residents. LPA was unable to interview the remaining two (02) residents.

Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards were noted during the visit.

Exit interview conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024

LIC9099 (FAS) - (06/04)

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