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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405801811
Report Date: 05/21/2025
Date Signed: 05/21/2025 11:01:50 AM

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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/16/2024 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20240816102248
FACILITY NAME:CYPRESS GARDEN HOME CAREFACILITY NUMBER:
405801811
ADMINISTRATOR:GABRIELA SOOFACILITY TYPE:
740
ADDRESS:824 JACANA COURTTELEPHONE:
(805) 904-6282
CITY:ARROYO GRANDESTATE: CAZIP CODE:
93420
CAPACITY:6CENSUS: DATE:
05/21/2025
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Gabriela Soo, AdministratorTIME COMPLETED:
11:05 AM
ALLEGATION(S):
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Staff not giving resident access to hearing aid.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) conducted a subsequent complaint visit to the facility above to deliver final findings in the complaint investigation. LPA met with Gabriela Soo and explained the purpose of the visit.

LPA De Leon conducted the initial 10-day visit on 08/21/2024 conducted staff interviews and requested and received records. LPA conducted witness interviews on 08/19/2024 at 3:40pm and 4:19pm, on 08/21/2024 and on 05/01/2025 at 10:01am.

On the allegation: Staff not giving resident access to hearing aid. LPA interviewed staff, witness and review medical records which revealed R1 did wear hearing aids. The hearing aids were brought to the facility on admission and when people came to visit R1, R1 did not have hearing aids in and visitors would have to request the help from staff to find them, or they were not put on the charger to charge, or the batteries were not in them to use. LPA reviewed the Safeguard for Property and Valuables it has declined written across the page and no signature of the residents or the responsible parties.
Continued 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025
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 5
Control Number 29-AS-20240816102248
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 GARDEN HOME CARE
FACILITY NUMBER: 405801811
VISIT DATE: 05/21/2025
NARRATIVE
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According to one witness interview this form was not given to the resident or RP on admission to fill it out. Another witness interview revealed the staff helped with hearing aids on several visits, but R1 also refused the hearing aids at other times and did not want to put them on with visitors. Staff and witness interviews revealed that you could speak in a clear loud voice and communicate with R1 and that is how R1 wanted to communicate at times. The facility did not feel responsible for taking care of the hearing aids and batteries. Based on the LIC. 602A medical records for R1, R1 wore hearing aids and needed assistance and R1 is able to refuse to wear them at times the facility accepted R1 into care knowing he needed assistance with hearing aids therefore the allegation is Substantiated at this time.


Exit interview conducted, copy of report and appeal rights printed for Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20240816102248
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 GARDEN HOME CARE
FACILITY NUMBER: 405801811
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/28/2025
Section Cited
CCR
87465(a)(3)
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(a)...: (3)When residents require prosthetic devices, vision and hearing aids, the staff shall be familiar with the use of these devices, and shall assist such persons with their utilization as needed. This requirement was not met as evidenced by:
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Administrator will review regulation 87465 and understand the requirements of staff and helping residents and provide training to staff in these requirements, send LIC 500 and proof of Licensee, administrator and staff training.
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Based on interview and medical records R1 wore hearing aid and the facility did not always assist R1 with the hearing aids when needed which poses a potential health, safety and personal rights 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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
08/16/2024 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20240816102248

FACILITY NAME:CYPRESS GARDEN HOME CAREFACILITY NUMBER:
405801811
ADMINISTRATOR:GABRIELA SOOFACILITY TYPE:
740
ADDRESS:824 JACANA COURTTELEPHONE:
(805) 904-6282
CITY:ARROYO GRANDESTATE: CAZIP CODE:
93420
CAPACITY:6CENSUS: 6DATE:
05/21/2025
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Gabriela Soo, AdministratorTIME COMPLETED:
11:05 AM
ALLEGATION(S):
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Staff left resident soiled in urine.
Resident sustained multiple UTI’s while in care of staff.
Resident sustained pressure sore while in care of staff.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) conducted a subsequent complaint visit to the facility above to deliver final findings in the complaint investigation. LPA met with Gabriela Soo and explained the purpose of the visit.

LPA De Leon conducted the initial 10-day visit on 08/21/2024 conducted staff interviews and requested and received records. LPA conducted witness interviews on 08/19/2025 at 3:40pm and 4:19pm, on 08/21/2024 and on 05/01/2025 at 10:01am.

On the allegation: Staff left resident soiled in urine. LPA interviewed staff and witness which revealed that Resident 1 (R1) had frequent urination and blood in urine upon admission to the facility and was on antibiotics for UTI when R1 went on Hospice Services. Staff do rounds every two hours and change or toilet residents at that time, if a resident asks for help the staff have to finish helping the resident they are with and follow up with the resident as soon as finished. Staff stated R1 was changed frequently and every two hours when needed. Continued 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20240816102248
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 GARDEN HOME CARE
FACILITY NUMBER: 405801811
VISIT DATE: 05/21/2025
NARRATIVE
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 LPA interviewed witness that revealed they had never seen R1 left soiled in urine, R1 had wounds, and those wounds never got worse and cleared up quickly which would not have occurred if R1 had been frequently left soiled in urine. Interviews also revealed R1 was having difficulty in the evening, became combative at times and refused care. Based on the evidence this allegation is deemed Unsubstantiated at this time.

On the allegation: Resident sustained pressure sore while in care of staff. LPA interviewed staff, witness and reviewed medical records which revealed R1 did have two pressure sores during R1’s time at the facility due to being bedridden or in a recliner chair all day, R1 did get staff assistance for rotating and turning according to Hospice recommendations for R1. According to Hospice R1’s pressure sores were caused from being bedbound with skin breakdown due to disease progression, the pressure sores did not get worse and one was cleared within 2 week period and the other within a month and that would not have happened if the facility was not taking care of R1 properly. Based on the evidence this allegation is deemed Unsubstantiated.

On the allegation: Resident sustained multiple UTI’s while in care of staff. LPA De Leon interviewed staff, witnesses and reviewed medical records which revealed R1 had a history of UTI’s, R1 was taking medication for UTI’s and when R1 was admitted to Hospice R1 had a current UTI and Medical records stated R1 had a history of UTI’s. Based on the evidence this allegation is deemed Unsubstantiated.


Exit interview conducted and copy of report printed for Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5