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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609978
Report Date: 11/26/2024
Date Signed: 11/26/2024 11:38:39 AM

Document Has Been Signed on 11/26/2024 11:38 AM - 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: 68DATE:
11/26/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Gina Rozaner TIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Esther Cortez conducted a Case Management - Deficiencies visit at the facility in conjunction with a complaint visit (Complaint Control #29-AS-20241122140616) . LPA met with Executive Director Gina Rozaner.

During facility tour conducted today with the Executive Director, the LPA and ED observed a housekeeping cart unattended at 10:48 a.m. in the Memory Care unit. The cart had a spray bottle of Clorox toilet bowl cleaner with Bleach.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D).

Exit interview conducted, todays reports and appeal rights were reviewed and provided to the ED..
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/26/2024
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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Document Has Been Signed on 11/26/2024 11:38 AM - It Cannot Be Edited


Created By: Esther Cortez On 11/26/2024 at 11:29 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: 11/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/26/2024
Section Cited
CCR
87309(a)

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87309 Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
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POC has been met, cleaning cart with cleaning solution was removed immidiately.
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Based on observation the licensee failed to comply with the section cited above as the LPA observed a bleach clening solution unattended in MC unit and accessable to residents in care which poses an immediate safety risk to clients 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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2024


LIC809 (FAS) - (06/04)
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