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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881316
Report Date: 02/22/2024
Date Signed: 02/22/2024 03:41:48 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/16/2024 and conducted by Evaluator Yolanda Delgado
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240216084658
FACILITY NAME:DESERT CYPRESS ELDERCAREFACILITY NUMBER:
331881316
ADMINISTRATOR:CAYABYAB, ARCITA AFACILITY TYPE:
740
ADDRESS:68905 HERMOSILLO ROADTELEPHONE:
(760) 459-3214
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY:6CENSUS: 5DATE:
02/22/2024
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Arcita Cayabyab, OwnerTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility does not provide a safe environment for the residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced at the facility for the purpose of initiating an investigation for the above allegation. LPA Delgado was granted entry and met with Caregiver, Farasari Tebbe. Administrator, Arcita Cayabyab arrived and was present during today's inspection. During the course of investigation, LPA conducted a facility inspection and interviewed four (4) residents and one (1) staff member.

On February 16, 2024, Community Care Licensing received a complaint alleging that facility failed to provide a safe and peaceful environment for residents. It was reported that a smoke detector was observed to not operate efficiently, chirping. LPA Delgado toured the facility and tested all smoke detectors in common areas and resident bedrooms. LPA Delgado observed that smoke detectors tested were operating, except the smoke detectors in Resident #1 and Resident #2’s bedrooms. There are two smoke detectors in R1’s bedroom and both were making sounds indicating that the battery needed to be changed.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
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 18-AS-20240216084658
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DESERT CYPRESS ELDERCARE
FACILITY NUMBER: 331881316
VISIT DATE: 02/22/2024
NARRATIVE
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(continued from page 1)

The smoke detector in R2’s room is installed but did not present any alerts indicating that it was working. There are fire detectors that are working and in close proximity of R1 and R2’s bedrooms that will alert occupants to a potential fire. During the inspection, LPA could hear the occasional beeping that LPA Delgado identified as coming from the direction of the non-operable smoke detectors. Information obtained from interviews conducted advised that the smoke detectors have been making alerts for 3 months and it was requested that the batteries were changed. It was advised that facility staff indicated they would change the batteries but did not do so. Therefore, based on observations and interviews, the allegation that facility does not provide a safe and peaceful environment for the residents is SUBSTANTIATED. The facility will be cited for Title 22, Division 6, Chapter 8, Section 87203.

An exit interview was conducted where this report, 9099-D, and appeal rights were discussed. Copies of the documents were provided to Administrator.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20240216084658
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: DESERT CYPRESS ELDERCARE
FACILITY NUMBER: 331881316
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/23/2024
Section Cited
HSC
87203
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87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. LPA Delgado observed that smoke detectors tested were operating, except the smoke detectors in Resident #1 and Resident #2’s bedrooms. There are two smoke detectors in R1’s bedroom and both were making sounds indicating that the battery needed to be changed. The smoke detector in R2’s room is installed but did not present any alerts indicating that it was working.
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Administrator will have a maintenance worker come to the facility to check all the smoke detectors and replace all the batteries for the chirping smoke detectors and will replace any smoke detectors that will need replacement batteries. Administrator will send a self-certifying statement to LPA Delgado that smoke detectors batteries have been replaced by POC due date by 5pm.
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This requirement is not met based as evidence by interview and observation. The licensee did not comply by not replacing the batteries when requested which poses a potential health, safety, or personal rights risk to persons 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: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3