567609978-6-14-2021-29-AS-JROS-C3YUWX-20210614155729

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609978
Report Date: 06/14/2021
Date Signed: 06/14/2021 03:58:51 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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:	567609978
ADMINISTRATOR:	GINA SALMAN		FACILITY TYPE:	740
ADDRESS:	1200 CYPRESS POINT LANE		TELEPHONE:	(805) 650-8000
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY:	89	CENSUS: 75	DATE:	06/14/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:42 AM
MET WITH:	Gina Salman		TIME COMPLETED:	03:38 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 Analysts (LPA's) JoAnn Rosales and Angel Ascencio conducted an unannounced Required -1 Year inspection. LPA's conducted a facility tour to inspect for infection control practices. Infection control practices were discussed with the Administrator. An inspection of the common area, random resident rooms and restrooms were conducted. Outdoor area toured- passageways are free of obstruction. PPE supplies were observed. LPA's observed the fire extinguishers fully charged. Administrator provided a copy of the System Record of Inspection and Testing dated 2/26/21 which indicates that the smoke detectors and pull stations were inspected and tested by Low Voltage Solutions, Inc. The carbon monoxide detectors were tested and were operable. During facility tour at 10:34 am LPA's observed Lysol disinfecting wipes, scissors, disinfectant, general purpose cleaner and dish soap in the Activity room accessible to residents. During facility tour at 10:42 am LPA's observed nitroglycerin tablets, air freshener, scissors and dish soap in resident #1 (R1's) unlocked room accessible to residents. During facility tour at 10:47 am LPA's observed air freshener in resident bathroom accessible residents. During facility tour at 11:03 am LPA's observed Lysol disinfecting wipes and scissors in Bistro accessible to residents. During facility tour at 11:09 am LPA's observed a paper cutter in an unlocked work room accessible to residents. During facility tour at 11:11 am LPA's observed cans of paint and porcelain like finish spray on a cart in a hallway accessible to residents. During facility tour at 11:13 am LPA's observed WD-40 lubricant, roach killer, spray paint, spray enamel, silicone, air freshener, porcelain like finish spray, disinfecting wipes, disinfectant spray, fire block sealant, goof off remover in unlocked maintenance room accessible to residents. During facility tour at 11:14 am LPA's observed screwdriver and Continued on 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

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 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 567609978
	VISIT DATE: 06/14/2021

NARRATIVE

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wrench in a maintenance cart accessible to residents. During facility tour at 11:16 am LPA's observed dish soap and ajax cleanser in staff lunchroom accessible to residents. During facility tour at 11:38 am hot water temperature tested at 120.9 F. in resident bathroom. During facility tour at 11:52 am LPA's observed muscle rub in R2's bedroom accessible to R2 . During facility tour at 12:04 pm LPA's observed 4 cans of paint, gardening trowel and fork, gasoline, granular algaecide, multi-surface cleaner concentrate, spray enamel and brominating tablets in outdoor cabinets accessible to residents. During a review of random resident records at 1:32 pm LPA's did not observe a physician's report on file for R1. LPA's reviewed R2's records at 1:56 pm which revealed that R2 is not able to administer and store own medication.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted, todays reports and appeals 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: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

LIC809 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 567609978
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observations, the licensee did not comply with the section cited above in resident bathroom as hot water temperature read at 120.9 degrees F. which poses an immediate safety risk to persons in care.
	POC Due Date: 06/14/2021
	Plan of Correction
1 2 3 4	Staff turned down water heater temperature during facility visit.

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observations and record review, the licensee did not comply with the section cited above as R1's nitroglycerin tablets and R2's muscle rub were accessible to residents which poses an immediate health risk to persons in care.
	POC Due Date: 06/15/2021
	Plan of Correction
1 2 3 4	Staff place items in a locked medication room duiring facility visit. Administrator stated that she will provide documentation of scheduled staff training regarding regulation 87465(h)(2) to CCL by 6/15/21.

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

LIC809 (FAS) - (06/04)

Page: 3 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 567609978
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observations and record review, the licensee did not comply with the section cited above as scissors, paper cutter, gardening tools, screwdriver and a wrench were observed throughout the facility which poses an immediate safety risk to persons in care.
	POC Due Date: 06/15/2021
	Plan of Correction
1 2 3 4	Staff placed items in an inaccessible location during facility visit. Administrator stated that she will provide documentation of scheduled staff training regarding regulation 87705(f)(1) to CCL by 6/15/21.

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observations and record review, the licensee did not comply with the section cited above as toxic substances, cleaning supplies and disinfectants were observed throughout the facility which poses an immediate health risk to persons in care.
	POC Due Date: 06/15/2021
	Plan of Correction
1 2 3 4	Staff placed items in an inaccessible location during facility visit. Administrator stated that she will provide documentation of scheduled staff training regarding regulation 87705(f)(2) to CCL by 6/15/21.

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

LIC809 (FAS) - (06/04)

Page: 4 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 567609978
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 51 resident records which poses a potential health and safety risk to persons in care.
	POC Due Date: 06/21/2021
	Plan of Correction
1 2 3 4	Administrator stated that they will provide a copy of R1's current medical assessment to CCL by 6/21/21.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

LIC809 (FAS) - (06/04)

Page: 5 of 5