197609090-8-22-2024-31-AS-NMAN-D93SBF-20240913134354

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609090
Report Date: 08/22/2024
Date Signed: 08/22/2024 02:40:02 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., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/03/2024 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20240503164134

FACILITY NAME:	CYPRESS RESIDENCE II		FACILITY NUMBER:	197609090
ADMINISTRATOR:	MONJE-DU, CHERY B		FACILITY TYPE:	740
ADDRESS:	25459 VIA IMPRESO		TELEPHONE:	(661) 670-8949
CITY:	VALENCIA	STATE: CA	ZIP CODE:	91355
CAPACITY:	6	CENSUS: 5	DATE:	08/22/2024
		UNANNOUNCED	TIME BEGAN:	09:48 AM
MET WITH:	Chery Monje-du, Administrator		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff did not seek timely medical attention for resident.
Resident sustained unexplained bruises while in care.
Staff did not ensure resident’s care needs were being met.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Abeye Duguma conducted a subsequent complaint visit to the facility to investigate the above allegations. LPA met with administrator, Chery Monje-du, and explained the reason for the visit.

--- Staff did not seek timely medical attention for resident.

It was alleged that resident was covered in a rash and had open wounds that were bleeding. To investigate the allegation, on 05/08/2024, LPA interviewed three (03) staff from around 12:30 PM to 1:30 PM and interviewed two (02) out of four (04) residents from around 1:30 PM to 2:15 PM. On 08/22/2024 at around 10:30 AM, LPA requested additional documents. During interviews with staff, all staff stated Resident #1 (R1) did not have any bleeding from open wounds but that they are aware of the rash. All staff stated the rash comes and goes.
(CONT on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

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

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20240503164134

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: 08/22/2024

NARRATIVE

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Staff added the rash was immediately treated with Calmoseptine to sooth and help promote healing. During interviews with residents, two (02) out of four (04) residents stated, if needed, that staff would seek medical attention timely. LPA was unable to interview the remaining two (02) residents. A review of R1’s most recent Kaiser Permanente hospital records do not indicate rash or open wound during the month in question.

Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

--- Resident sustained unexplained bruises while in care.

It was alleged that resident had bruises on their nose. To investigate the allegation, on 05/08/2024, LPA conducted a physical plant tour at around 11:30 AM, interviewed three (03) staff from around 12:30 PM to 1:30 PM and interviewed two (02) out of four (04) residents from around 1:30 PM to 2:15 PM. On 08/22/2024, LPA requested additional documents. During the physical plant tour, LPA did not observe any signs of abuse. During interviews with staff, all staff stated R1 did not have a bruise on the nose, rather it was redness from R1 continuously scratching their nose. Staff added antibiotic ointment was applied to the scratched area three times a day to sooth and help promote healing. A review of R1’s most recent Kaiser Permanente hospital records do not indicate that resident had any bruises or abrasions on their nose during the time in question.

Based on observations, interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

- Staff did not ensure resident’s care needs were being met.

It was alleged that resident was not showered and repositioned in bed. To investigate the allegation, on 05/08/2024, LPA interviewed three (03) staff from around 12:30 PM to 1:30 PM and interviewed two (02) out of four (04) residents from around 1:30 PM to 2:15 PM. On 08/22/2024, LPA requested documents. During the physical plant tour, LPA did not experience any malodor and observed that all residents were clean and well groomed.
(LIC9099-C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20240503164134

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: 08/22/2024

NARRATIVE

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During interviews with staff, all staff stated facility residents are showered a minimum three times a week or more depending on their needs. Staff added R1 was not bedridden and did not require assistance with repositioning in bed but often reminded R1 to reposition anyway. During interviews with residents, two (02) out of four (04) residents stated they shower at least twice a week or more if they like, but do not require assistance with repositioning. A review of the resident’s Physician’s Report revealed that resident was not bedridden and did not require assistance with repositioning in bed.

Based on observations, interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards were noted during the visit.

Exit interview conducted and a copy of the report was issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

LIC9099 (FAS) - (06/04)

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