565850555-12-2-2025-29-AS-KHEN-DPRBHA-20251227000512

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850555
Report Date: 12/02/2025
Date Signed: 12/02/2025 04:04:42 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. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/30/2025 and conducted by Evaluator Kelly Dulek

COMPLAINT CONTROL NUMBER: 29-AS-20251130231129

FACILITY NAME:	CYPRESS PLACE ASSISTED LIVING		FACILITY NUMBER:	565850555
ADMINISTRATOR:	ROZANER, GINA		FACILITY TYPE:	740
ADDRESS:	1200 CYPRESS POINT LANE		TELEPHONE:	(805) 650-6000
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY:	89	CENSUS: 71	DATE:	12/02/2025
		UNANNOUNCED	TIME BEGAN:	09:58 AM
MET WITH:	Gina Rozaner		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff are mishandling a resident's medication

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced initial complaint visit regarding the above noted allegation. LPA was greeted by the front desk staff and met with Executive Director (ED) Gina Rozaner. LPA explained the purpose of the visit. Entrance interview conducted.

During today's visit, LPA interviewed ED at 10:11AM, staff at 10:26AM, Resident #1 (R1) at 10:52AM, toured the facility at 11:26AM, interviewed R1's family member telephonically at 12:51PM, and conducted a medication review for R1 at 01:37PM. LPA also reviewed and obtained copies of pertinent documents.

The complaint alleges that the facility staff did not administer pain medication to R1 for two (2) days and that as a result, R1 was experiencing chest pain and trembling. Record review revealed that R1 moved into the facility in early November. R1's care plan included medication management and physician's report also

Report Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025

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 29-AS-20251130231129

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 PLACE ASSISTED LIVING	FACILITY NUMBER: 565850555
	VISIT DATE: 12/02/2025

NARRATIVE

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indicated R1 does require assistance with medications and that R1 cannot have alcohol due to R1's prescribed medications. Upon move in, R1 had a total of 59 tablets of Oxycodone 5mg brought into the facility. R1's Oxycodone 5mg was prescribed to take one (1) tablet three (3) times a day. R1's medications were administered beginning 11/05/2025 and the last remaining dose was administered at 08:00AM on 11/25/2025. LPA reviewed communications with R1's primary care physician (PCP) dated 11/13/2025 informing R1's PCP that R1 has been consuming alcohol. R1's PCP wrote to the facility indicating "tell [R1] we won't refill pain medications if [R1] drinks alcohol with it." Interview with facility staff and management revealed there have been multiple attempts to assist R1 in obtaining prescribed pain medications, but to date, opioid medications have not been refilled. Although attempts have been made at multiple pharmacies, the prescription has been unable to be filled due to not receiving the orders from R1's medical provider and one (1) pharmacy indicated they are conducting an investigation into potential forgery. R1 also has a prescribed pain patch, which does appear to be administered as prescribed. Interview with R1 revealed the facility staff are helpful and nice. R1 even stated there are multiple facility staff trying to get R1's medications straight, but that R1 hasn't received their medication in about a week. R1 also mentioned they do not currently have the means to pay the co-pay for their medications until a new card arrives on Friday. Telephone call with R1's family member revealed they were aware R1 had not received their medications and stated this issue is "all on [R1.]" R1's family member indicated they believe the facility is doing what they can to assist R1 and they have no concerns with the facility. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is deemed UNSUBSTANTIATED at this time.

No citations issued. Exit interview conducted. A copy of today's report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025

LIC9099 (FAS) - (06/04)

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