565850555-5-8-2025-29-AS-TCAA-DGGUBG-20250508152618

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850555
Report Date: 05/08/2025
Date Signed: 05/08/2025 03:27:43 PM

Document Has Been Signed on 05/08/2025 03:27 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	CYPRESS PLACE ASSISTED LIVING		FACILITY NUMBER:	565850555
ADMINISTRATOR/ DIRECTOR:	ROZANER, GINA		FACILITY TYPE:	740
ADDRESS:	1200 CYPRESS POINT LANE		TELEPHONE:	(805) 650-6000
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY: 89		CENSUS: 70	DATE:	05/08/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Gina Rozaner		TIME VISIT/ INSPECTION COMPLETED:	03:40 PM

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	Licensing Program Analyst (LPA) Teresa Camara conducted a pre-licensing visit to the above noted facility. The LPA met with administrator Gina Rozaner. This facility is currently operating under a different license (facility number 567609978). This is a change of ownership application. A dementia program was included in the plan of operation. A Hospice Waiver has been requested. The facility is two-story. There are memory care and assisted living rooms on both floors. At 9:45 a.m., a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for a total capacity of 89 residents, of which 19 may be non-ambulatory and 70 may be bedridden. The facility has an automatic fire sprinkler system which was last inspected by the County Fire Protection on 3/5/2025. Fire extinguishers were observed throughout the facility and were last inspected 3/5/2025. The facility maintains smoke and carbon monoxide detectors and they are tested monthly by maintenance staff. Residents choose to bring their own furnishings to their rooms. All resident rooms are set up with beds, nightstands, lighting, chests of drawers, chairs and closet space. The beds have box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. All rooms were free of odors. Window screens were clean and in good repair. There are no staff rooms at the facility. (continued on LIC809-C, page 2)

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Teresa Camara
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CYPRESS PLACE ASSISTED LIVING	FACILITY NUMBER: 565850555
	VISIT DATE: 05/08/2025

NARRATIVE

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(continued from LIC809, page 1)

Each bedroom has a private bathroom. There are nine (9) shared bedrooms which have night-lights in the shared bathroom. There are grab bars in the showers and next to the toilets. All showers have non-skid mats. The hot water temperature measured between 114.1*F - 118.3*F, which falls within the allowable range of 105*F - 120*F.

Resident and staff records are stored in the business office. Medications are centrally stored in locked medication carts in the Wellness Office along with the first aid supplies. Personal Protective Equipment (PPE) is stored in a room on the second floor.

Residents do not have access to the commercial kitchen. Knives are stored in the kitchen. The kitchen was clean and the appliances were all functional. The walk-in refrigerator and freezer were well stocked with the perishable food supply. The freezer was maintained at 0*F and the refrigerator was at 40*F. Non-perishable foods are stored in the kitchen and in a locked room on the second floor along with an emergency water supply. The food supply is sufficient. There is a sufficient supply of dishes, utensils, and drink ware. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. No flies or other vermin were observed.

The common areas were appropriately furnished, and the lighting was adequate. There are televisions in the media room in memory care. Activities are held inside the activity room and outside on the patios. The activities director posts a calendar of scheduled activities. The elevator is functional and permitted. Night lights were maintained in hallways and passageways to public bathrooms. The stairwells are equipped with emergency evacuation chairs. The memory care units have delayed egress on all doors and digital keypads to enter/exit the units. The physical plant is consistent with the submitted facility sketch/floor plan. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit.

(continued on LIC809-C, page 3)

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Teresa Camara
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CYPRESS PLACE ASSISTED LIVING	FACILITY NUMBER: 565850555
	VISIT DATE: 05/08/2025

NARRATIVE

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(continued from LIC809-C, page 2)

Staff do the laundry for the residents on scheduled days. Residents typically choose to supply their own linens, bath towels, and personal hygiene items (soap, shampoo), however the facility will supply these items if necessary. The facility also keeps extra incontinence supplies. There is a functioning telephone on the premises and residents are offered privacy to use the phone. All required postings were observed in both assisted living and memory care. Fireplaces were observed to have screens.

The exterior passageways were clean and clear of any obstructions. There are covered patio areas and seating for both memory care and assisted living residents. There were no bodies of water observed.

There were no deficiencies observed. This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Teresa Camara
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025

LIC809 (FAS) - (06/04)

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