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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609090
Report Date: 12/06/2023
Date Signed: 12/06/2023 04:37:05 PM

Substantiated


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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/30/2023 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20231130154148
FACILITY NAME:CYPRESS RESIDENCE IIFACILITY NUMBER:
197609090
ADMINISTRATOR:MONJE-DU, CHERY BFACILITY TYPE:
740
ADDRESS:25459 VIA IMPRESOTELEPHONE:
(661) 670-8949
CITY:VALENCIASTATE: CAZIP CODE:
91355
CAPACITY:6CENSUS: 5DATE:
12/06/2023
UNANNOUNCEDTIME BEGAN:
12:46 PM
MET WITH:Chery Monje-DuTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff did not keep toxins inaccessible to persons other than employees.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to the facility. LPA met with Licensee, Chery Monje-Du, and explained the reason for the visit.

--- Staff did not keep toxins inaccessible to persons other than employees.

It was alleged that staff left magnet key that stores toxins accessible to residents in the main restroom on a paper towel. To investigate this allegation, on 12/06/2023, LPA made observations at around 12:30 PM and interviewed three (03) staff from around 1:00 PM – 2:30 PM. LPA observed cleaning supply storage cabinet to be locked and keys in possession of staff. During interviews, Staff #1 stated that they only heard about the incident, Staff #2 stated that they did not know anything about the incident and Staff #3 stated they are aware of the incident and took steps to immediatley train and remind staff not leave the magnetic key in a places accessible to residents.
(CONT. LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
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 3
Control Number 31-AS-20231130154148
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: CYPRESS RESIDENCE II
FACILITY NUMBER: 197609090
VISIT DATE: 12/06/2023
NARRATIVE
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Based on interviews, there is enough information to verify the allegation, therefore, the allegation is SUBSTANTIATED at this time, however a plan of correction was not implemented as the Licensee took immediate steps to train and meet with staff to review regulation.

No health and safety hazards noted during the visit.

Exit interview was conducted and a copy of report was issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20231130154148
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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CYPRESS RESIDENCE II
FACILITY NUMBER: 197609090
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/06/2023
Section Cited
CCR
87705(f)(2)
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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) …. toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
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A POC was not issued as the Licensee provide immediate training and met with staff to review regulation. A copy of the Service Meeeting was provided.
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Based on interviews, the licensee did not ensure that toxins were inaccessible to residents in care which poses a potential Health, Safety, or Personal Rights risk to persons 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.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3