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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405801811
Report Date: 02/09/2022
Date Signed: 02/09/2022 02:10:14 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, 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
02/04/2022 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20220204112436
FACILITY NAME:CYPRESS GARDEN HOME CAREFACILITY NUMBER:
405801811
ADMINISTRATOR:GABRIELA SOOFACILITY TYPE:
740
ADDRESS:824 JACANA COURTTELEPHONE:
(805) 904-6282
CITY:ARROYO GRANDESTATE: CAZIP CODE:
93420
CAPACITY:6CENSUS: 5DATE:
02/09/2022
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Staff Caregiver Laney RivasTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility not following protocol to prevent the spread of COVID-19
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Leon conducted an onsite 10-day Complaint visit to the facility above. LPA met with the Staff Caregiver Laney Rivas and staff called Administrator. Administrator talked to LPA by phone and is unable to meet due to being out of town today for an appointment. LPA explained the purpose of the visit and Administrator authorized staff to sign report.

LPA took tour of the facility with Staff. LPA interviewed Staff and residents. LPA requested the following documentation: Staff Roster with Telephone numbers, Staff Schedule for February 1, 2022-February 9, 2022, Resident Roster, Resident Emergency ID form with contacts. Administrator will provide documents requested by tomorrow.

Continued 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022
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 29-AS-20220204112436
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: 02/09/2022
NARRATIVE
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On the allegation: Facility not following protocol to prevent the spread of COVID-19. LPA interviewed credible witness, staff and residents regarding the allegation. Staff (S1) interview revealed the facility has visitors and masks are always worn by staff in the facility. Residents 1 and 2 (R1)(R2) interviews stated the staff are always wearing masks when helping them in the facility. A creditable witness (W1) stated W1 knocked on door and the staff caregiver answered the door not wearing a mask. Based on credible witness statement this allegation is deemed Substantiated at this time.

Exit interview conducted, deficiency cited, copy of report and appeal rights emailed to Licensee/Administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20220204112436
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
02/10/2022
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents...: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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Administrator agreed to hold infectious control training, review and train staff on all recent PIN’s released for 2022, including masks wearing mandated, and provide copy of training and staff signatures to CCL.
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Based on interview with W1 the licensee did not comply with regulation above due to S2 answered the door without a mask on which poses an immediate health and safety risk to residents 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.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3