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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609978
Report Date: 06/19/2024
Date Signed: 06/19/2024 02:38:57 PM


Document Has Been Signed on 06/19/2024 02:38 PM - It Cannot Be Edited

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 LIVINGFACILITY NUMBER:
567609978
ADMINISTRATOR:GINA SALMANFACILITY TYPE:
740
ADDRESS:1200 CYPRESS POINT LANETELEPHONE:
(805) 650-8000
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:89CENSUS: 75DATE:
06/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:27 AM
MET WITH:Gina Rozaner, AdministratorTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection at the above-named facility. Upon arrival, LPA was greeted by Staff 1 (S1) and Administrator Gina Rozaner. During today’s visit, there were 75 residents in care. In the Assisted Living unit there were three (3) caregivers and one (1) medication technician on duty. In the memory care unit, there were 3 caregivers, one med tech, the Memory Care Director and the Program Coordinator on duty. The Director of Wellness who oversees Assisted Living and Memory Care was also present during the visit.
LPA explained the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) and is home to non-ambulatory residents with a dementia diagnosis. There are 12 residents currently on hospice, 27 residents with a dementia diagnosis, 10 residents currently on oxygen, and 4 bedridden residents in care.
Entrance interview conducted:
The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. The facility was seen to be in good repair inside and outside.
A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster and Resident’s Rights. LPA inspected the facility for fire safety and other hazards.
There are approximately 16 fire extinguishers throughout the facility and 13 fire pull alarms. The pull fire alarms alert the local fire department when activated. Fire inspection was most recently conducted on 5/26/2024.
The kitchen area was sufficiently stocked with two-day perishables and seven days of non-perishables. Snacks and beverages are readily available for Residents. LPA observed the dining areas are clean. LPA observed kitchen area and kitchen service area to be clean and in good repair.

Please continue to 809-C, Pg 2.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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: 06/19/2024
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 Activities are co-mingled with Assisted Living Residents and Memory Care residents. Activities include special occasion celebrations, happy hour with live entertainment, music entertainment and therapy, various exercise activities, card games, Bingo, various types of tournaments, travel presentations, physical therapy, art projects, cooking demonstrations, trivia, cognitive provoking activities, therapy animals, support group therapy, non-denominational spiritual services, as well as scenic drives and excursions to local eateries and retail businesses. The facility participates in the “Rev in Motion” program through the Vitality Program.
Due to time restraints, LPA will continue the Annual Inspection at a later date.
Exit interview conducted. Copy of report issued at the time of the visit.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC809 (FAS) - (06/04)
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