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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567609978
Report Date: 03/24/2022
Date Signed: 03/24/2022 05:54:48 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/15/2022 and conducted by Evaluator Joann Rosales
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20220315171928
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
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Gina SalmanTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Resident is not being provided a comprehensive description for items and services on their Admission Agreement.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) JoAnn Rosales made an unannounced complaint visit to this facility for the above complaint allegations. LPA met with Administrator Gina Salman.

During today's complaint investigation visit LPA toured the facility with the Administrator, reviewed random resident records and conducted interviews with random staff and residents. Concerns were that resident #1 (R1) was not provided a comprehensive description for items and services on their Admission Agreement. Based on a review of R1's records starting at 10:59 am LPA observed that R1 is being charged for services under Care Fees without a comprehensive description of and the corresponding fee schedule of what those services are that are being provided. Interview with Administrator at 5:06 pm revealed that the Admission Agreement the facility is using was approved by Community Care Licensing when they were licensed in June 2020. Based on the information obtained during the course of the investigation the allegation is deemed

Continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 29-AS-20220315171928
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/24/2022
NARRATIVE
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substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D):

Exit interview conducted. Today's report was reviewed and emailed to the Administrator.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
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
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/15/2022 and conducted by Evaluator Joann Rosales
COMPLAINT CONTROL NUMBER: 29-AS-20220315171928

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
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Gina SalmanTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Resident is being charged for services not received.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) JoAnn Rosales made an unannounced complaint visit to this facility for the above complaint allegations. LPA met with Administrator Gina Salman.

During today's complaint investigation visit LPA toured the facility with the Administrator, reviewed random resident records and conducted interviews with random staff and residents. Concerns were that resident #1 (R1) was being charged for services not received. Based on interviews conducted and record review at 3:20 pm LPA observed that R1 is being charged for periodic evaluation of ability to self manage medications. R1 was evaluated by facility staff on 3/1/22 for the ability to manage medications. Based on the information obtained during the course of the investigation the allegation is deemed unsubstantiated at this time.

Exit interview was conducted, today's report was reviewed and emailed to the Administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
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.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20220315171928
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/04/2022
Section Cited
CCR
87507(g)(B)
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87507 Admission Agreements (g)(B) Rate for additional items and services, including: 1. A comprehensive description of and the corresponding fee schedule for all additional items and services not included in the fees for basic services shall be listed.

This requirement is not met as evidenced by:
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Administrator stated that they will documentation of an updated Admission Agreement to include a comprehensive description of and the corresponding fee schedule for all additional items and services not included in the fees for basic services to CCL by 4/4/22.
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Based on interviews and record review, the licensee did not comply with the section cited above as R1's Admission Agreement does not provide a comprehensive description of and the corresponding fee schedule what services are being provide under Care Fees which poses a potential personal rights 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 HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
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
LIC9099 (FAS) - (06/04)
Page: 4 of 4