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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609978
Report Date: 10/06/2021
Date Signed: 10/06/2021 06:32:35 PM

Document Has Been Signed on 10/06/2021 06:32 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: 78DATE:
10/06/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Gina SalmanTIME COMPLETED:
04:44 PM
NARRATIVE
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This Case management visit was conducted to address the deficiencies noted during complaint control #29-AS-20210928150733 investigation visit conducted on 10/6/21.

During facility tour on 10/6/21 with Administrator Gina Salman starting at 11:19 am LPA observed bathroom porcelain & tile cleaner, floor cleaner and disinfectant cleaner in an unlocked storage closet on the first floor accessible to residents. During facility tour on 10/6/21 with Administrator at 10:59 am LPA observed dish soap in an unlocked cabinet in the staff lounge accessible to residents. During facility tour on 10/6/21 with staff Lilly Duarte at 11:32 am LPA observed gardening tools in an unlocked outdoor cabinet accessible to residents.


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 were reviewed and emailed to the Administrator.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021
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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Document Has Been Signed on 10/06/2021 06:32 PM - It Cannot Be Edited


Created By: Joann Rosales On 10/06/2021 at 12:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CYPRESS PLACE ASSISTED LIVING
FACILITY NUMBER: 567609978

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/18/2021
Section Cited
CCR
87705(f)(1)

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87705 Care of Persons with Dementia(f)(1) The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
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Staff placed gardening tools in an inaccessible location during facility visit. Administrator stated that they will provide documentation of staff training regarding regulation 87705(f)(1) to CCL by 10/18/21.
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Based on LPA's observations and record review, the licensee did not comply with the section cited above as gardening tools were observed accessible to residents which posed an immediate health risk to persons in care.
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Type A
10/18/2021
Section Cited
CCR87705(f)(2)

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87705 Care of Persons with Dementia(f)(2) The following shall be stored inaccessible to residents with dementia: 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:
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Administrator locked storage closet and staff placed dish soap in an inaccessible location during facility visit. Administrator stated that they will provide documentation of staff training regarding regulation 87705(f)(2) to CCL by 10/18/21.
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Based on LPA's observations and record review, the licensee did not comply with the section cited above as cleaning supplies and disinfectants in a storage closet and dish soap in staff lounge were accessible to residents which posed an immediate health risk to persons in care.
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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
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2021


LIC809 (FAS) - (06/04)
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