<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609978
Report Date: 06/18/2020
Date Signed: 06/19/2020 08:47:01 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE. SUITE 200
GOLETA, CA 93117
FACILITY NAME:CYPRESS PLACE ASSISTED LIVINGFACILITY NUMBER:
567609978
ADMINISTRATOR:SPIRA, STEVENFACILITY TYPE:
740
ADDRESS:1200 CYPRESS POINT LANETELEPHONE:
(805) 650-8000
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:89CENSUS: 67DATE:
06/18/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Steven Spira and Christina HarrisTIME COMPLETED:
02:02 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) JoAnn Rosales conducted a Pre-licensing tele-visit with Administrator Steven Spira and applicant representative Christina Harris due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures. This application is a change of ownership from Cypress Place Assisted Living #565801008. Applicant representative attended Component III in the Rohnert Park office on 1/13/2020.

LPA inspected facility for Fire Safety, Personal Accommodations and Services, Medication Procedures, and Food Service. First-aid kit is complete, facility has adequate linen, water and nonperishable food supplies.

Facility has 8 private and 4 shared rooms in memory care floor 1, 19 private rooms in assisted living floor 1, 5 private and 3 shared rooms in memory care floor 2 and 37 private rooms in assisted living floor 2. All resident units have private bathrooms. Signal system was tested and operable. Hot water temperature tested at 114 degrees Fahrenheit in resident bathroom. The common areas were appropriately furnished and lighting was adequate. There is additional entertainment equipment and games for activities. Resident and staff records are kept in a locked cabinet in the business office. Resident medications are kept in locked medication carts in the 1st floor medication room. Disinfectants, cleaning solutions and poisons are kept inaccessible. LPA observed smoke detectors and carbon monoxide detectors operating properly and fire extinguishers properly charged. Fire clearance is approved for 89 non-ambulatory residents of which 70 may be bedridden.

The physical plant is in compliance with Title 22 regulations at this time.

A telephonic exit interview was conducted with Administrator Steven Spira, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1