565801008-3-29-2022-29-AS-KHEN-CDAMLQ-20220408094239

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801008
Report Date: 03/29/2022
Date Signed: 03/29/2022 01:03:45 PM

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
06/02/2020 and conducted by Evaluator Joann Rosales

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20200602160313

FACILITY NAME:	CYPRESS PLACE ASSISTED LIVING		FACILITY NUMBER:	565801008
ADMINISTRATOR:	SPIRA, STEVEN P		FACILITY TYPE:	740
ADDRESS:	1200 CYPRESS POINT LN		TELEPHONE:	(805) 650-8000
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY:	0	CENSUS: 80	DATE:	03/29/2022
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Gina Salman		TIME COMPLETED:	01:03 PM

ALLEGATION(S):

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Facility staff handle residents in a rough manner
Facility staff yell at residents
Facility staff do not treat residents with respect

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) JoAnn Rosales conducted a subsequent unannounced complaint investigation visit to deliver final investigation findings. LPA met with Administrator Gina Salman.

Concerns were that staff #1 (S1) handled residents in a rough manner. Interviews with random residents and staff on 3/24/22 starting at 11:59 am revealed that staff have not observed any staff handling any residents in a rough manner and residents have not been handled in a rough manner by any staff. Concerns were that S1 yelled at residents. Interviews with random residents and staff on 3/24/22 starting at 11:59 am revealed that staff have not observed any staff yelling at any residents and residents have not been yelled at by any staff. Concerns were that S1 does not treat residents respect. Interviews with random residents and staff on 3/24/22 starting at 11:59 am revealed that staff have not observed any staff treating residents disrespectfully and residents have not been treated disrespectfully by staff. S1 when interviewed on 3/28/22 at 12:11 pm

Continued on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

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-20200602160313

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 PLACE ASSISTED LIVING	FACILITY NUMBER: 565801008
	VISIT DATE: 03/29/2022

NARRATIVE

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denied handling residents in a rough manner, yelling at residents, and treating residents disrespectfully. Based on the information obtained, there is not sufficient evidence to support the allegations, therefore the allegations Facility staff handle residents in a rough manner, Facility staff yell at residents, and Facility staff do not treat residents with respect are deemed unsubstantiated at this time.

Exit interview conducted today's reports and appeal rights were reviewed and emailed to the Administrator

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

LIC9099 (FAS) - (06/04)

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