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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609978
Report Date: 03/24/2022
Date Signed: 03/24/2022 05:59:20 PM

Document Has Been Signed on 03/24/2022 05:59 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: 80DATE:
03/24/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Gina SalmanTIME COMPLETED:
05:58 PM
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Licensing Program Analyst (LPA) JoAnn Rosales conducted a Case Management - Deficiencies visit at the facility. LPA met with Administrator Gina Salman.

During facility tour on 3/24/22 with the Administrator starting at 9:59 am LPA observed a hammer, spot remover, floor cleaner stainless steel polish and pond, stream and waterfall treatment in the 1st floor laundry room accessible to residents. Administrator stated that the door was locked. LPA was able to open the door as the door was not completely shut and there were no staff in the laundry room. Administrator stated that they recently adjusted the tension on the door as it used to slam shut. During facility visit at 1:25 pm LPA observed that staff #1 (S1) is working at the facility and is not fingerprint cleared and associated to the facility. Administrator stated that S1 works for a Home Care Agency and worked at the facility on 3/17, 3/18, 3/22 and today 3/24/22. Administrator stated that they did not know that S1 had to be associated to the facility.

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

Civil penalties in the amount of $250.00, $250.00 and $400.00.

Exit interview conducted, todays reports, civil penalties and appeal rights were reviewed and emailed to the Administrator.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2022
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 03/24/2022 05:59 PM - It Cannot Be Edited


Created By: Joann Rosales On 03/24/2022 at 11:41 AM
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: 03/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/24/2022
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 adjusted the tension on the laundry room door during facility visit so that the door will close shut when staff leave the room.
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Based on LPA's observations and record review, the licensee did not comply with the section cited above as a hammer was observed accessible to residents which posed an immediate health risk to persons in care.
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Type A
03/24/2022
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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Staff adjusted the tension on the laundry room door during facility visit so that the door will close shut when staff leave the room.
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Based on LPA's observations and record review, the licensee did not comply with the section cited above as toxic substances 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: 03/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/24/2022 05:59 PM - It Cannot Be Edited


Created By: Joann Rosales On 03/24/2022 at 05:20 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: 03/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/24/2022
Section Cited
CCR
87355(e)(1)

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87355 Criminal Record Clearance(e)(1) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department.
This requirement is not met as evidenced by:
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S1 requires to obtain criminal record clearance. Administrator stated that they will associate S1 through Guardian and will not employ S1 unless criminal record clearance is obtained and associated with the facility.”
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Based on interview and record review, the licensee did not comply with the section cited above as they did not obtain a criminal record clearance for S1 which poses an immediate safety 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: 03/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022


LIC809 (FAS) - (06/04)
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