567609978-6-20-2023-29-AS-ECOZ-CSXW4Y-20230619165818

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609978
Report Date: 06/19/2023
Date Signed: 06/20/2023 05:02:01 PM

Document Has Been Signed on 06/20/2023 05:02 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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	CYPRESS PLACE ASSISTED LIVING		FACILITY NUMBER:	567609978
ADMINISTRATOR:	GINA SALMAN		FACILITY TYPE:	740
ADDRESS:	1200 CYPRESS POINT LANE		TELEPHONE:	(805) 650-8000
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY:	89	CENSUS: 70	DATE:	06/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Gina Salman		TIME COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At 09:30 a.m. Licensing Program Analysts (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by Executive Director (ED) Gina Salman and informed them of the reason for the visit. At 09:35 a.m. the LPA conducted a tour of the physical plant with ED Gina to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was noted: Facility is a double story residence that consists of Units designated for assisted living residents and memory care residents on both floors. The LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced on 03/15/2023. The smoke alarms and carbon monoxide detectors were tested and were operable. Administrator provided report dated 03/15/23 from County Fire Protections which indicates all smoke detectors in the common areas were tested and passed the test. The LPA observed all required postings outside of the dining room. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. Kitchen: The LPA began the inspection in the kitchen/food service area at 09:35 a.m. Knives and cleaning supplies are stored inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 10:05 a.m., the LPA and Dinning Service Director Marco Cadena observed a variety of breads in the refrigerator with no expiration label. Breads found were three (3) packages of English muffins, and approximately eighteen (18) white sandwich bread packages. The Dinning Service Director stated that they recently received the bread on 06/10/2023 and showed the LPA the vendor invoices. At 10:02 a.m., the LPA observed a container with seven (7) purple onions with mold. The Dinning Service Director directed kitchen staff to discard the purple onions upon observation. Repot will continue on LIC809-C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CYPRESS PLACE ASSISTED LIVING	FACILITY NUMBER: 567609978
	VISIT DATE: 06/19/2023

NARRATIVE

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Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents in both outside courtyards of the Assisted Living unit and Memory Care Unit. Parking is available for residents and visitors. There are no bodies of water on the premises.

Record Review: At 12:30 p.m. a review of facility files was initiated. The LPA observed documentation of Infection Control, Disaster prevention and last fire drill (conducted on 06/12/2023). The LPA obtained Client Roster, Staff Roster, and facility Sketch.

Interviews: Between 10:30 a.m. and 12:00 p.m., the LPA conducted five (5) resident Interviews.

Due to time constraints the LPA will return to complete the annual at a later date.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

LIC809 (FAS) - (06/04)

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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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CYPRESS PLACE ASSISTED LIVING	FACILITY NUMBER: 567609978
	VISIT DATE: 06/19/2023

NARRATIVE

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Bedrooms: The resident bedrooms were properly furnished with at least one chair, night-stand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. At 11:32 a.m., the LPA observed four (4) steak knives in the kitchenette drawer of room 203. Room 203 was locked at the time of the visit and the LPA reviewed resident’s (R1) Physician report which noted resident has good physical health, no dementia, and is able to self-care.

Bathrooms: During the facility tour the LPA observed a random selection of resident bathrooms on both floors. The LPA observed all bathrooms properly supplied, with functional fixtures, grab bars and non-skid strips. Residents have sufficient amounts of supplies for personal hygiene. At 10:31 a.m., the LPA observed spilled soap between the sink and toilet in the bathroom of bedroom 109. At 10:47 a.m., the LPA observed water leaking from the toilet creating a small puddle of water in the bathroom of room 131. At 10:59 a.m., the LPA observed the bathroom in room 102 unkempt with a soiled toilet. At 11:30 a.m. the LPA observed the bathroom in bedroom 203 with dirt residue streaks on the floor in front of the toilet. At 11:40 a.m., the LPA observed the bathroom unkempt in memory care room 160 with a soiled toilet and at 11:44 a.m., the bathroom in memory care room 164 was observed to have soiled floors in front of the toilet. Upon observation, the ED directed staff and Maintenance Director to clean all observed bathrooms and fix any water leakages. The LPA conducted water temperature checks between 10:51 a.m. through 12:20 p.m., and the hot water measured ranged between 78.7 degrees Fahrenheit to 114.8 degrees Fahrenheit. The Maintenance Director stated the water measuring at 78.7 degrees Fahrenheit in room 131 had the valve underneath the sink turned off and turned it back on upon observation. The LPA re-measured the water temperature in room 131, which measured at 109.4 degrees Fahrenheit.

Common Areas: Common spaces were clean and in good repair. No obstructions and/or tripping hazards observed. These included the dining area, private dining room, bistro, and activity room. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Both fireplaces in the dining room and Bistro were observed to be adequately screened. The facility maintained a comfortable temperature of 73 degrees. There were no obstructions and/or tripping hazards throughout the facility.

Report will continue on LIC809-C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

LIC809 (FAS) - (06/04)

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