567609978-10-25-2023-29-AS-KLOZ-CZUUCN-20240126142812

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 567609978
Report Date: 10/25/2023
Date Signed: 10/25/2023 12:00:25 PM

Unsubstantiated

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
10/18/2023 and conducted by Evaluator Elsie Campos

COMPLAINT CONTROL NUMBER: 29-AS-20231018161932

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:	10/25/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Gina Rozaner		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Staff is not properly treating bed bugs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Elsie Campos conducted an unannounced initial 10-day complaint visit for the above allegation. The LPA was scanned and greeted at the door by Staff. The LPA met with Executive Director,Gina Rozaner and was explained the reason for the visit.

During today's inspection, the LPA conducted interviews and a tour of the facility at 11:10 a.m. and also conducted a record review and reviewed and obtained copies of other pertinent documents relevant to the investigation.

Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

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-20231018161932

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: 567609978
	VISIT DATE: 10/25/2023

NARRATIVE

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Allegation: Staff is not properly treating bed bugs

It was alleged that staff is not properly treating bed bugs. Based on the interviews conducted it was revealed that the facility has had a recurring bed bug issue in a single isolated room #162 but the facility has taken action. Currently the isolated room with the infestation is being treated and the resident was relocated to a shared room approximately one day after the discovery of the infestation. The resident will not be placed back into their room until the facility has received clearance from the extermination company that the room is bed bug free. Administrator confirmed that the family would be given a copy of the clearance letter once it is received. Interviews and records reviewed, revealed that facility’s reoccurring issues with bed bugs in this same room have been a result of items being brought into the unit from outside of the facility such as old clothes, furniture, and/or miscellaneous items. Record review revealed that bed bugs have been maintained with the assistance of Western Exterminators on a regular basis. The extermination company has made additional recommendations to the facility to monitor for any future bed bug re-infestation as this has been a reoccurring issue, such as placing glue boards along the base boards to identify any potential future infestation. Administrator stated facility has the exterminator company come once a month and/or when needed to treat for any bed bug re-infestation. Record review also confirmed that the facility reported the discovery of bed bugs to Licensing on 10/12/2023. For any bed bug issues facility staff/management is alerted and pest control is scheduled to have each identified room/area with bed bug issue serviced accordingly and immediately. The Administrator stated that on a routine room check, concerns were brought to their attention regarding room 162 of a possible bed bug infestation and the exterminators were called immediately along with maintenance who immediately bagged and conducted cleaning protocols to control the infestation as soon as possible. At 11:10 a.m., the LPA observed the room to have been cleared, the mattress was propped up away from the walls along with other furniture in preparation for an additional fumigation on 10/26/2023. Interviews reported no bed bug issues or concerns in any other rooms. Based on interviews, record review and observation, there is insufficient evidence to support the allegation that "Staff is not properly treating bed bugs” and is deemed UNSUBSTANTIATED at this time.

No deficiencies observed. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC9099 (FAS) - (06/04)

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