567609978-6-20-2022-29-AS-JROS-CFKUFS-20220620153315

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609978
Report Date: 06/20/2022
Date Signed: 06/20/2022 03:34:29 PM

Document Has Been Signed on 06/20/2022 03:34 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 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: 81	DATE:	06/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Gina Salman		TIME COMPLETED:	03:33 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	Licensing Program Analyst (LPA) JoAnn Rosales conducted an unannounced Required -1 Year inspection. LPA met with Administrator Gina Salman. During facility tour to inspect for infection control practices LPA observed one central entry point designated for universal entry screening. Cleaning supplies were observed and infection control practices were discussed. An inspection of the common area, resident rooms and restrooms were conducted hot water temperature (read at 116.1, 107.3, 114.2, 103.9 and 119.6 degrees F.) in resident bathrooms. Grab bars were present in the bathrooms. Hygiene items are being provided. LPA observed a sufficient supply of perishable and nonperishable food. LPA observed working signal system. LPA observed appropriate lighting in the facility. LPA observed the fire extinguishers fully charged. The smoke alarms and carbon monoxide detectors were tested and were operable. Administrator provided report dated 2/28/22 from Low Voltage Solutions which indicates 47 smoke detectors in the common areas were tested and passed the tests. Medications are centrally stored and are kept in locked medication carts and locked medication room. First Aid kit is complete. LPA observed a sufficient supply of PPE. Outdoor area toured- passageways are free of obstruction. During facility tour with Administrator at 11:15 am LPA observed staff #1 (S1) working at the facility and is fingerprint cleared but not associated to the facility. Interview with S2 at 2:29 pm revealed that S1 starting working at the facility on 1/3/22 and has worked 88 days. During facility tour with Administrator starting at 12:04 pm LPA observed resident #1 (R1)'s smoke detector missing from their bedroom and living room ceilings. Interview with S3 starting at 12:44 pm revealed that they were aware that a night staff removed one of the smoke detectors in R1's bedroom as it was beeping at night. Continued on 809C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/20/2022

NARRATIVE

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S3 stated that it was removed about a week ago and they were not aware of the second smoke detector being removed.

During facility tour with Administrator starting at 12:04 pm LPA observed Ricola cough suppressant and oral analgesic drops and Glade air freshener in R2's room accessible to R2.

During facility tour with Administrator starting at 12:47 pm LPA observed Ecolab lime away disinfectant, stainless steel cleaner and polish, Viper coil cleaner, and Zep fast 505 degreaser in an outside unlocked shed 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):

Civil Penalties issued in the amount of $500.00, $250.00 and $500.00.

Exit interview conducted, todays reports, civil penalties and appeals rights were reviewed and emailed to the Administrator.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 06/20/2022 03:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Type A

Section Cited

CCR

87203

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observations and interview, the licensee did not comply with the section cited above as R1's smoke detectors were missing which poses an immediate health and safety risk to persons in care.
	POC Due Date: 06/20/2022
	Plan of Correction
1 2 3 4	Staff replaced the smoke detectors in R1's bedroom and living room during facility visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 06/20/2022 03:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) 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:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observations and record review, the licensee did not comply with the section cited above as cough suppressants and toxic items were accessible to residents which poses an immediate health risk to persons in care.
	POC Due Date: 06/21/2022
	Plan of Correction
1 2 3 4	Staff placed cough suppressants and toxic items in inaccessible locations during facility visit. Administrator stated that they will provide documentation of scheduled inservice training regarding regulation 87705(f)(2) to CCL by 6/21/22.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 06/20/2022 03:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Deficiency Dismissed

Type A

Section Cited

CCR

87355(e)(2)

Criminal Record Clearance

(e) 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: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation and record review, the licensee did not comply with the section cited above as S1 requires transfer of crimal record clearance which poses an immediate safety risk to persons in care.
	POC Due Date: 06/20/2022
	Plan of Correction
1 2 3 4	S1 requires transfer of crimal record clearance . Staff associated S1 through Guardian during facility visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022

LIC809 (FAS) - (06/04)

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