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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803756
Report Date: 09/29/2025
Date Signed: 09/29/2025 08:21:53 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/07/2025 and conducted by Evaluator Shannan Hansen
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20250207092702
FACILITY NAME:CYPRESS HOMEFACILITY NUMBER:
216803756
ADMINISTRATOR:ROJAS, MONAFACILITY TYPE:
735
ADDRESS:856 CYPRESS AVETELEPHONE:
(415) 895-1399
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY:4CENSUS: 4DATE:
09/29/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Ivy Payumo, DesigneeTIME COMPLETED:
08:45 AM
ALLEGATION(S):
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Resident sustained unexplained injury while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to deliver findings for a Complaint Investigation regarding the above allegation and met with designee Ivy Payumo. LPA spoke with Administrator, Mona Rojas via phone who authorized for designee to sign for today’s visit.

During the investigation, the Department reviewed facility and medical records, police reports, conducted interviews, and made observations. The following allegation was investigated, “Resident sustained unexplained injury while in care”. The complainant alleges that Resident (R1) sustained a fractured femur during R1’s incontinent briefs being changed. The complainant stated that R1 did not have any signs of osteoporosis and questioned if the facility had handled R1 in a rough manner causing the injury. Records review revealed that R1 has a history of being combative during incontinent brief changes and medical records indicate that R1 has a diagnosis of severe osteoporosis. Based on Department review of facility and medical records diagnosis and police report, the injury that R1 sustained cannot be attributed to negligent action on the part of the facility during incontinent brief change. Continue on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2025
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 2
Control Number 21-AS-20250207092702
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CYPRESS HOME
FACILITY NUMBER: 216803756
VISIT DATE: 09/29/2025
NARRATIVE
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Continued from LIC9099

A distal femur fracture could have happened while R1 was being combative and resistant to care. R1’s comorbidities made R1 prone to fracture even at low energy trauma. R1 had been mostly bedbound for a few years, a risk factor for osteoporosis. In addition, interviews with staff and outside parties did not indicate staff handled R1 in a rough manner during incontinent brief changes.

Although the allegation, Resident sustained unexplained injury while in care may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

No citations given at today's visit

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2