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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609978
Report Date: 11/06/2023
Date Signed: 11/06/2023 03:43:43 PM


Document Has Been Signed on 11/06/2023 03:43 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 LIVINGFACILITY NUMBER:
567609978
ADMINISTRATOR:GINA SALMANFACILITY TYPE:
740
ADDRESS:1200 CYPRESS POINT LANETELEPHONE:
(805) 650-8000
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:89CENSUS: 75DATE:
11/06/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:28 PM
MET WITH:Gina RozanerTIME COMPLETED:
03:50 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Martha Arroyo and Brian Balisi conducted an unannounced Case Management - Deficiencies visit today. Upon arrival, LPAs met with Executive Director (ED), Gina Rozaner and explained the reason for the purpose. The purpose of the visit is to issue a citation for a deficiency observed during the complaint investigation.

During the complaint investigation of complaint # 29-AS-20210928150733, the following deficiencies were observed: Resident #1 (R1) had several unwitnessed falls while living at the facility which resulted in R1 sustaining scrapes, skin tears, and/or body pain and receiving 1st aid from facility staff. Record review of resident’s notes revealed R1 suffered an unwitnessed fall on 06/04/2021, 06/21/2021, 06/25/2021, and 08/31/2021; however, R1 was not reassessed from the original Assessment conducted on 05/27/2023 which stated on page 3 of 4 that R1 ‘does not require status checks’ even after R1 had been found multiple times on the floor due to unwitnessed falls. Furthermore, the numerous unwitnessed falls noted indicated R1 was not being provided with the proper level of care and supervision resulting in repeated unwitnessed falls while living at the facility.

The following deficiency was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. Citation issued. A copy of the appeal rights and report were provided.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2023
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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Document Has Been Signed on 11/06/2023 03:43 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: 11/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/13/2023
Section Cited
HSC
1569.312(a)

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Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2

This requirement is not met as evidenced by:
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Licensee has agreed to submit a plan and how the facility plans on providing the proper level of care and supervision to residents in care and submit to CCLD by 11/13/2023.
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Based on interviews and records review, the licensee did not comply with the section cited above as Licensee failed to provide adequate care and supervision to R1 resulting in R1 sustaining multiple unwitnessed falls in the facility, which posed an immediate health and safety risk to residents 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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2