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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609978
Report Date: 05/08/2025
Date Signed: 05/08/2025 03:20:58 PM

Document Has Been Signed on 05/08/2025 03:20 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:CYPRESS PLACE ASSISTED LIVINGFACILITY NUMBER:
567609978
ADMINISTRATOR/
DIRECTOR:		GINA SALMANFACILITY TYPE:
740
ADDRESS:1200 CYPRESS POINT LANETELEPHONE:
(805) 650-8000
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY: 89CENSUS: 70DATE:
05/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Gina RozanerTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Teresa Camara started the required annual visit in conjunction with a change of ownership pre-licensing visit. LPA met with Executive Director (ED) Gina Rozaner and explained the reason for the visit.

The facility is two-story. There are memory care and assisted living rooms on both floors. At 9:45 a.m., a physical plant tour was conducted inside and out. The facility has a fire clearance for a total capacity of 89 residents, of which 19 may be non-ambulatory and 70 may be bedridden. The facility has an automatic fire sprinkler system which was last inspected by County Fire Protection on 3/5/2025. Fire extinguishers were observed throughout the facility and were last inspected 3/5/2025. The facility maintains smoke and carbon monoxide detectors and they are tested monthly by maintenance staff.

Residents do not have access to the commercial kitchen. Knives are stored in the kitchen. The kitchen was clean and the appliances were all functional. The walk-in refrigerator and freezer were well stocked with the perishable food supply. The freezer was maintained at 0*F and the refrigerator was at 40*F. Non-perishable foods are stored in the kitchen and in a locked room on the second floor along with an emergency water supply. The food supply is sufficient. There is a sufficient supply of dishes, utensils, and drink ware. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. No flies or other vermin were observed.

(continued on LIC809-C)
NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Teresa Camara
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: CYPRESS PLACE ASSISTED LIVING
FACILITY NUMBER: 567609978
VISIT DATE: 05/08/2025
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(continued from LIC809)

Common areas were observed to be clean and adequately furnished. The facility has activity calendars posted. Required postings were observed throughout the facility in both assisted living and memory care. LPA observed group activities taking place in memory care and assisted living. The elevator was functional and permitted. Stairwells have emergency evacuation chairs.

LPA entered ten (10) resident rooms; all were appropriately furnished and lighting was sufficient. All bedrooms have their own bathroom. There are nine (9) shared rooms in which the shared bathrooms have night-lights. There are grab bars in the showers and next to the toilets. All showers have non-skid mats. The hot water temperature measured between 114.1*F - 118.3*F, which falls within the allowable range of 105*F - 120*F.

No deficiencies observed. LPA will return at a later date to finish this annual inspection.
NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Teresa Camara
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
LIC809 (FAS) - (06/04)
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