567609978-10-30-2023-29-AS-DPEA-CX5VFB-20231031162339

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 567609978
Report Date: 10/30/2023
Date Signed: 10/30/2023 02:04:08 PM

Unsubstantiated

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
09/28/2021 and conducted by Evaluator Martha Arroyo

COMPLAINT CONTROL NUMBER: 29-AS-20210928150733

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: 75	DATE:	10/30/2023
		UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Gina Rozaner		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Resident sustained multiple falls while in care.
Facility staff did not dispense medication as prescribed.
Facility failed to follow Admission Agreement.
Facility staff did not safeguard resident's personal property.
Facility did not have an Activities Director.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent visit to the facility to issue findings for the above allegations. The initial visit was conducted on 10/26/2021 by LPA J. Rosales and a subsequent visit was conducted on 07/13/2023 by LPA M. Arroyo. During today's visit, LPA met with Executive Director, Gina Rozaner and the reason for the visit was explained. Entrance interview.

During the initial visit on 10/26/2021, LPA Rosales toured the facility, conducted interviews with random staff, and obtained copies of pertinent documents. On 07/13/2023, LPA Arroyo conducted interviews with one staff member and six residents between 12:50 p.m. and 1:30 p.m., conducted a file review at 1:45 p.m., and obtained a copy of the census and other pertinent documents. Additionally, the LPA conducted telephonic interviews with family members on 09/28/2023 at 11:37 a.m. and 10/03/2023 at 2:15 p.m. and 3:00 p.m.

(Report Continued on LIC 9099C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023

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-20210928150733

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: 10/30/2023

NARRATIVE

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(Report Continued from LIC 809...)

It was alleged that resident sustained multiple falls while in care. It was reported that Resident #1 (R1) had several falls but was only taken out to the hospital once. Information gathered during the course of the investigation revealed R1 was admitted to the facility on 06/01/2021. Per Physicians Report dated 05/12/2021, it indicated R1’s cognitive status included being confused and disoriented. Review of documents revealed that R1 suffered at least four (4) falls within ninety (90) days. On three (3) of those falls, R1 was observed by staff, and it was noted that R1 had skin tears, scrapes, and/or complained of having body pain and facility staff administered first aid to R1. Interviews with staff revealed R1 had had several falls while living at the facility. These falls were reported to have occurred inside R1’s bedroom, R1’s bathroom, and while in the dining room. Review of documents revealed that facility was actively communicating with R1’s POA regarding R1’s falls and making sure R1 was assessed and cared for. Furthermore, record review revealed R1 was seen by their PCP shortly after the falls. Based on the information and documentation obtained and reviewed, the Department does not have sufficient evidence to support the allegation is due to facility/staff neglect. Therefore, the allegation is deemed Unsubstantiated at this time.

It was alleged that facility staff did not dispense medication as prescribed. It was reported that Resident #1 (R1) was complaining of having pain and R1’s doctor called the facility to prescribe Tylenol for pain; however, the facility did not give R1 any pain medication. Record review of R1’s medication log revealed R1 was taking four (4) medications at the time R1 had reported feeling body pain. However, pain medication such as Tylenol was not a medication listed for R1 as either a routine medication or as a PRN. A physician’s order for PRN Tylenol was not issued to R1; therefore, facility staff were not able to administer pain medication. Interviews conducted with staff revealed R1’s family had requested pain medication be given to R1 on the day R1 had suffered an unwitnessed fall in their room. Staff stated R1’s family had given R1 Tylenol after the facility staff refused to give pain medication to R1 earlier in the day. Staff stated they had reported fall to R1’s Primary Care Physician (PCP) and had requested pain medication be prescribed; however, R1’s family had taken R1 out of the facility before the facility could administer pain medication to R1. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “facility staff did not dispense medication as prescribed”. Therefore, this allegation is being Unsubstantiated at this time.

(Report Continued on LIC 9099C...)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 29-AS-20210928150733

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: 10/30/2023

NARRATIVE

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(Report Continued from LIC 9099C...)

It was also alleged that facility failed to follow Admission Agreement. It was reported that R1’s family was still being charged thirty (30) days after the move out date. Information gathered during the course of the investigation revealed R1 was admitted to the facility on 06/01/2021 and left the facility on 09/03/2021. Per Admissions Agreement signed by R1’s Power of Attorney (POA) on 05/27/2021, it states on page 16 Section 21.01 Vacating Apartment that “the resident or resident’s estate shall remain liable for the monthly fee for core services until the effective termination date and all property is removed…” Interviews conducted with staff revealed R1’s POA moved R1 out of the facility without giving the facility the proper thirty (30) day notice. Additionally, staff stated R1’s ledger report included the dates of 09/04/2021 – 09/30/2021 and also included a credit for the month of October as their Admissions Agreement states the facility will charge the remaining days of the month and not thirty (30) days following discharge date. Furthermore, R1’s POA received a bill that included the basic services for the month of September only. Therefore, based on all information gathered during the course of the investigation, the above allegation, “facility failed to follow Admissions Agreement” is being deemed Unsubstantiated at this time.

It was also alleged that facility staff did not safeguard resident’s personal property. It was reported that shortly after R1 moved into the facility, R1’s hearing aids went missing. Information obtained and reviewed revealed that on R1’s Physician’s Report dated 05/24/2021 it was noted that R1 used hearing aids. Additionally, per R1’s Admissions Agreement signed on 05/14/2023, Page 10 indicates R1’s POA signed and acknowledged receiving a copy of the facility’s “Community’s Theft and Loss Policy” and on the Client/Resident Personal Property and Valuables form for R1 was filed; however, neither R1 nor R1’s POA listed R1’s hearing aids upon admission to the facility. Also, residents have a Resident Theft and Loss Record in their file which is used to report any items that go missing while living at the facility, and upon review, the form was empty as neither R1 nor R1’s POA listed any items missing while living at the facility and after leaving the facility. Interviews conducted with staff revealed they had observed R1 using hearing aids while they assisted R1 but were not aware of R1’s hearing aids being missing. Family member interviews further revealed that residents have not reported personal items gone missing while living at the facility. Based on all the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “facility staff did not safeguard resident’s personal property”. Therefore, this allegation is being deemed Unsubstantiated at this time.

(Report Continued on LIC 9099C...)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20210928150733

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: 10/30/2023

NARRATIVE

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(Report Continued from LIC 9099C...)

It was further alleged that facility did not have an Activities Director. It was reported that the facility was looking for a new activities director and went without an activity director for at least two (2) months. Interviews conducted with staff revealed the Memory Care Director was handling the duties of the Activities Director while they had the vacancy. Additionally, other staff available in the facility were filling in to do activities with the residents. Interviews conducted with random residents revealed the facility offers activities daily. Interviews conducted with family members revealed there are activities being offered to the residents every day and there is always something to keep the residents engaged and busy. Furthermore, although the memory care unit did not have an assigned activities director for a short period of time, several facility staff including the assisted living activities director were providing and encouraging memory care residents to participate in activities on a daily basis. Based on the information gathered during the course of the investigation, the Department does not have sufficient evidence to support the above allegation of “facility did not have an Activities Director”. Therefore, this allegation is being deemed Unsubstantiated at this time.

Exit interview conducted. No citations issued at this time. A copy of the report was provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023

LIC9099 (FAS) - (06/04)

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