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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374600378
Report Date: 11/25/2024
Date Signed: 11/25/2024 01:24:30 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
11/21/2024 and conducted by Evaluator Janette Romero
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20241121150339
FACILITY NAME:CYPRESS COURT ESCONDIDOFACILITY NUMBER:
374600378
ADMINISTRATOR:ROB JOHNSTONFACILITY TYPE:
740
ADDRESS:1255 N. BROADWAYTELEPHONE:
(760) 747-1940
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY:293CENSUS: 159DATE:
11/25/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrator, Tania DupreTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility roof is in disrepair
INVESTIGATION FINDINGS:
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On 11/25/2024, Licensing Program Analyst (LPA), Janette Romero made an unannounced visit to investigate the allegation listed above. LPA met with Administrator, Tania Dupre who was informed of the purpose of the visit.

It was alleged there are various leaks in the roof throughout the facility affecting resident rooms, the dining room, and hallways. LPA conducted a tour of the interior of the facility with Administrator Dupre and at the time of the visit there was no active leaks observed. However, it was not observed to be raining outside. Administrator Dupre and Maintenance Director, Ismael Damian identified the areas and resident rooms that have been affected by the leaks in the roof. Administrator Dupre stated that the roof was previously repaired, however some leaks are still present and the roof is scheduled to be repaired in 2025. LPA reviewed the facility's 2023 Roof Survey dated 6/27/2023 providing an estimate for several roof repairs/maintenance actions recommended to be completed immediately. LPA observed the hallway near room 357 with brown spots in the ceiling where Administrator Dupre identified to have knowledge of water leaking in 2023.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 529-2930
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
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-20241121150339
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CYPRESS COURT ESCONDIDO
FACILITY NUMBER: 374600378
VISIT DATE: 11/25/2024
NARRATIVE
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Four (4) residents were interviewed and all reported to have knowledge of water leaking in the dining room during 2023's rainy season. LPA toured the bedroom shared by Resident 1 (R1) and Resident 2 (R2) and observed what appeared to be a plastic grocery bag taped to the ceiling directly above R1 and R2's bed. R1 and R2 were interviewed and reported water has been leaking through the fire sprinkler for the past three (3) years anytime it rains heavily. R1 and R2 reported Staff 1 (S1) placed the plastic grocery plastic bag over the fire sprinkler to contain the leaking water. S1 was interviewed and confirmed taping the bag to the bedroom ceiling of the room shared by R1 and R2 in order to temporarily contain the leaking water to avoid it from landing on R1 and R2's bed. Administrator Dupre reported they were unaware facility staff taped the plastic grocery bag to R1 and R2's bedroom ceiling as a temporary solution. Administrator Dupre stated they will have a contractor repair the ceiling in R1 and R2's bedroom by 12/9/2024.

Based on LPA’s observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations (Title 22, Division 6, Chapter 9), are being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided to Administrator Dupre along with the Confidential Names list (LIC 811) and Appeal Rights.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 529-2930
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20241121150339
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: CYPRESS COURT ESCONDIDO
FACILITY NUMBER: 374600378
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/09/2024
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Licensee reported they will have a contractor repair the ceiling in the bedroom shared by R1 and R2 and provide proof of correction to LPA by close of business on POC due date.
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Based on observations, interviews conducted, and record review the facility roof is in disrepair as water continues to leak throughout different areas of the facility, including R1 and R2's room. This poses a potential health, safety, or personal rights risk to residents in care.
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Licensee added they will ensure
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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.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 529-2930
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3