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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507005324
Report Date: 12/29/2020
Date Signed: 12/29/2020 11:45:32 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/18/2020 and conducted by Evaluator Treana White
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200918115606
FACILITY NAME:CYPRESS ASSISTED LIVINGFACILITY NUMBER:
507005324
ADMINISTRATOR:MELINA NUNEZFACILITY TYPE:
740
ADDRESS:1801 NORTH OLIVE AVENUETELEPHONE:
(209) 410-7243
CITY:TURLOCKSTATE: CAZIP CODE:
95382
CAPACITY:49CENSUS: 13DATE:
12/29/2020
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Melina Nunez, AdministratorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Resident needs not being met.
Resident not being provided adequate food service.
INVESTIGATION FINDINGS:
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On 12/29/2020, Licensing Program Analyst (LPA) T. White contacted the facility to commence a complaint investigation via telephone due to COVID-19 and pre-cautionary measures. LPA White discussed the purpose of the call and the elements of the allegations with Administrator, Melina Nunez.

During the course of this investigation, the department conducted interviews and collected documentation. Based on interviews, 5 of 6 residents stated the staff is willing to help with their current needs. On 11/05/2020, LPA interviewed 3 staff members. 3 of 3 staff stated they have not received complaints from residents regarding proper care. However, LPA left messages with 1 of 6 residents and was unable to speak with resident.

Report continues on LIC9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: 510-566-9324
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2020
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 27-AS-20200918115606
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: CYPRESS ASSISTED LIVING
FACILITY NUMBER: 507005324
VISIT DATE: 12/29/2020
NARRATIVE
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Based on interviews, Responsible Party (RP) stated Resident #1 (R1) does not like facility’s meals. RP stated R1 eats an alternative meal, which is peanut butter and jelly sandwiches quite often. On 11/05/2020, LPA T. White interviewed 5 residents regarding adequate food services. Based on interviews, 2 of 6 residents stated the food does not change and needs improvements, LPA observed facility’s menu is updated and there are alternative meal items for the residents to choose daily. Based on documentation and interview with Staff #4(S4), the facility has a number of alternative meals for the residents to choose. However, 3 of 6 residents stated they enjoy the food and staff accommodates food choices. LPA left messages with 1 of 6 residents and was unable to speak with resident.

Based on information obtained, LPA determined these allegations to be UNSUBSTANTIATED- means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. There are no citations being issued today.

Exit interview conducted with Administrator, Melina Nunez and copy of report provided.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: 510-566-9324
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2020
LIC9099 (FAS) - (06/04)
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