405801811-3-30-2022-29-AS-KBUY-CD227F-20220330170841

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405801811
Report Date: 03/30/2022
Date Signed: 03/30/2022 11:30:05 AM

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. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/31/2020 and conducted by Evaluator Rachael De Leon

COMPLAINT CONTROL NUMBER: 29-AS-20200731142532

FACILITY NAME:	CYPRESS GARDEN HOME CARE		FACILITY NUMBER:	405801811
ADMINISTRATOR:	GABRIELA SOO		FACILITY TYPE:	740
ADDRESS:	824 JACANA COURT		TELEPHONE:	(805) 904-6282
CITY:	ARROYO GRANDE	STATE: CA	ZIP CODE:	93420
CAPACITY:	6	CENSUS: 5	DATE:	03/30/2022
		UNANNOUNCED	TIME BEGAN:	11:11 AM
MET WITH:	Leini Rivas, Staff Back up to Administrator		TIME COMPLETED:	11:35 AM

ALLEGATION(S):

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Staff denied resident access to a walker.
Staff are not ensuring resident's dietary needs are met.
Staff did not ensure resident's care needs were met.
Resident's bathing needs are not met.
Facility denied Resident access to phone calls.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rachael De Leon conducted a subsequent complaint visit to the facility above to deliver final findings of the complaint allegations. LPA met with Back up to to Administrator Leini Rivas and explained the purpose of the visit.

LPA Mark Jeffries conducted the initial investigation on 08/06/2020 at 1:40 PM, LPA Jeffries conducted interviewed and requested documentation. LPA De Leon conducted a subsequent visit on 02/09/2022 from 12:15 PM to 2:15 PM, LPA conducted interviews with staff and residents, requested documents, and toured the physical plant. LPA De Leon conducted additional interviews with witness on 03/21/2020 at 3:46 PM and resident interview on 03/22/2022 at 3:00 PM.

Continued 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

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 29-AS-20200731142532

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CYPRESS GARDEN HOME CARE	FACILITY NUMBER: 405801811
	VISIT DATE: 03/30/2022

NARRATIVE

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On the allegation: Staff denied resident access to a walker. LPA interviewed witness, staff and residents which revealed that R1 did not have R1’s own walker, the facility walker was provided to R1 for use and R1 did utilize the walker. R1’s interview revealed that R1 had no issues with access to a walker at anytime R1 was at the facility. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time.

On the allegation: Staff are not ensuring resident's dietary needs are met. LPA interviewed witness, staff, resident and reviewed documentation which revealed R1 did have a diet restriction on dairy. The facility staff interview revealed they followed the nondairy diet and R1 was provided Almond Milk with meals. Witness interview revealed R1 liked certain things to eat and certain meals which was not normal for the facility to provide so the admission agreement stated R1’s friend would provide some of R1’s food. Staff interviews revealed that salmon was purchased and provided to R1 regularly as that is what R1 like to eat. R1 stated the facility at some point provided everything R1 needed and it was not an issue. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time.

On the allegation: Staff did not ensure resident's care needs were met. LPA interviewed Staff, Witness Residents, and documentation which revealed the staff provided care, supervision and the residents needs were being met. A third-party agency visited R1 at the facility and no notation were made about needs not being met. R1’s interview revealed R1 was able to rehabilitate and leave the facility to be on R1’s own. R1 did feel the facility was short staffed and if staffed additionally the residents needs could have been met better as sometimes you had to wait for the staff to be available if the staff was dealing with another resident, the staff were attentive and did their job. Based on the lack of evidence this allegation is Unsubstantiated at this time.

On the allegation: Resident's bathing needs are not met. LPA interviewed staff, residents, and reviewed shower documentation. The documentation revealed that R1 was showered regularly. Staff interviews revealed each resident had a shower schedule and showers are documented on file and any refusals are noted. Continued 9099-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20200731142532

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CYPRESS GARDEN HOME CARE	FACILITY NUMBER: 405801811
	VISIT DATE: 03/30/2022

NARRATIVE

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R1’s interview revealed R1 was showered regularly, they were quick showers lasting minutes getting R1 in the shower, wet, washed and out of the shower. R1 did not have any issues with R1’s shower schedule. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time.

On the allegation: Facility denied Resident access to phone calls. LPA interviewed Staff, witness, and residents which revealed the facility did have a working telephone and it was available for resident use. R1’s interviewed revealed R1 had no issues with the telephone and R1 had R1’s own cell phone to make calls. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time.

Exit interview conducted, no deficiencies cited, copy of report emailed to Administrator/Licensee.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

LIC9099 (FAS) - (06/04)

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