<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607807
Report Date: 11/19/2025
Date Signed: 11/19/2025 09:58:34 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/14/2025 and conducted by Evaluator Leslie Ngo-Castaneda
COMPLAINT CONTROL NUMBER: 31-AS-20250514110207
FACILITY NAME:CYPRESS RESIDENCEFACILITY NUMBER:
197607807
ADMINISTRATOR:CHERY B. MONJE-DUFACILITY TYPE:
740
ADDRESS:25787 SALCEDA ROADTELEPHONE:
(661) 260-3447
CITY:VALENCIASTATE: CAZIP CODE:
91355
CAPACITY:6CENSUS: 6DATE:
11/19/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jovita Saldo- DesigneeTIME COMPLETED:
10:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not ensure resident is turned/rotated resulting in resident sustaining pressure injuries.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At approximately 9:00 AM on 11.19.2025, Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an unannounced, subsequent complaint visit. LPA met with staff and disclosed the reason for the visit.

To investigate the allegation above, LPA conducted an initial visit on 5.21.2025 and toured the facility inside and out at 9:05AM. LPA interviewed staff, residents, and their family members between 10:44 AM and 2:00 PM. LPA conducted a record review of pertinent records, including but not limited to a physician report, admission agreement, appraisal needs and service plan, hospital discharge after visit summary (AVS), and other pertinent records at 2:00 PM. Copies records requested and received at 2:45PM. Today, LPA toured the facility at 9:45 AM.

Regarding the allegation “Staff do not ensure resident is turned/rotated, resulting in resident sustaining pressure injuries,” Continue to LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
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 3
Control Number 31-AS-20250514110207
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: CYPRESS RESIDENCE
FACILITY NUMBER: 197607807
VISIT DATE: 11/19/2025
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
26
27
28
29
30
31
32
It was alleged that on 5/11/2025 resident #1 (R1) was admitted to the hospital. Upon admission it was found that R1 had 4 pressure injuries on his upper and lower back. It was reported that R1 sits in a recliner most of the day or is in bed, No turning assistance was provided to avoid or relief pressure injuries.
During LPA visit on 5.21.2025, it was observed that the staff continued to care for R1 at the facility. The interview with the administrator and staff at 10:44 AM revealed that staff were instructed to reposition R1 every two (02) hours. Interview with Staff #1 (S3) at 11:00 AM on 5.16.2025 confirmed that all staff had been trained by a vendor for R1’s care. LPA observed staff repositioned R1 every two (02) hours, assisted with incontinence care, and ensured their wounds were dry and free of redness. LPA interviewed R1 at 12:00 PM and stated that staff constantly check, reposition, and transfer them to their chair recliner/ bed from time to time. Interviews with five (5) out of six (6) other residents interviewed revealed they have no issues with pressure injuries. An interview with R1 family revealed that they are happy with the care given by the facility and were not aware that R1 should be at a higher level of care.

A review of R1’s initial assessment revealed they had no history or signs of skin breakdown as of 11.20.2024 during admission. LPA reviewed R1 medical documents revealed that R1 was admitted to the ER on 4.22.2025 and on 5.12.2025 for other health concerns. On 4.22.2025, a stage 3 pressure injury was already observed on the thoracic (back) region. Then on 5.12.2025 at the time of admission to the hospital, the following pressure injuries were observed; sacral stage 3, extending to the right (R) buttock; Right (R) Thoracic- Unstageable; Medial Location Thoracic- Unstageable; Left hip Deep Tissue Injury (DTI) Stage 3. R1 was discharged and returned to the facility with home health (HH) wound care on 5.16.2025.
Overall investigation revealed that R1 developed prohibited health condition (Stage 3 Pressure injuries) while in care of the facility. Although R1 was receiving home health care services for a wound care and staff was providing required assistance, between 04.22.25 and 05.22.25, pressure injuries were not healing. After both hospitalization R1 was readmitted to the facility with stage 3 pressure injuries, which was requiring higher level of care.

Therefore, based on inspection, observation, interviews and record review, the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on the LIC 9099-D page .An immediate civil penalty of $500.00 was issued for continuing to retain and readmit R1 to the facility with prohibited health condition which requires higher level of care. The Administrator was informed that additional civil penalties will be issued under Health & Safety Code 1569.49(f). Exit interview conducted. Appeal rights discussed. Copy of report provided.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20250514110207
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CYPRESS RESIDENCE
FACILITY NUMBER: 197607807
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/20/2025
Section Cited
CCR
87615(a)(1)
1
2
3
4
5
6
7
Prohibited Health Condition:
Persons who require health services for or have a health condition, including, but not limited to, Stage 3 and 4 pressure injuries, shall not be admitted or retained in a residential care facility for the elderly. This requirement was not met, as
1
2
3
4
5
6
7
As POC, within 24 hours, the administrator will provide written plan of action explaining steps they will take to avoid similar issues from happening again. Written statement should verify that a Licensed consultant will be hired to provide additional training to address
8
9
10
11
12
13
14
 evidenced by medical records received and interviews with home health staff conducted by IB, confirming R1 sustaining multiple stage 3 wounds.
8
9
10
11
12
13
14
 this section of the regulation. A copy of the training log, the training topic, and attendance shall be submitted to the Licensing agency by 11.20.2025.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3