Cypress Place Assisted Living

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management visit to the facility. The case management visit is being conducted to discuss a self-reported Special Incident Report (SIR) that was reported to Community Care Licensing on 08/27/26 regarding resident #1 (R1) and staff #1 (S1). On 08/27/26, it was self-reported that on 08/6/26, a visitor had reported that they observed a care staff (S1) being abrupt, impatient and some what physical when performing a task with Resident 1 (R1). During today's visit, the LPA conducted interviews with the Executive Director, Director of Wellness, Business Office Director (BOD), R1, conducted phone interviews with two (2) witnesses, attempted to conduct a phone interview with S1, reviewed S1's records, and obtained copies of pertinent documents. Interviews with two (2) witnesses revealed that S1 was seen poking/jabbing R1's arm. Witness 1 (W1) revealed that it was inappropriate of S1 to poke S1 and could have redirected them in a different manner. Witness 2 (W2) revealed that they observed S1 jerk the wheelchair very ubrupt and forceful before R1 could place their feet on the foot rest. W2 stated that they do not believe S1 was hurting R1, however they felt it was very unnecessary and unkind. The LPA attempted to interview R1, however R1 has a diagnosis of dementia. R1 did not know who S1 was or where they were at. R1 stated to the LPA that they currently feel safe. S1 is no longer working at the facility and the LPA was not able to interview S1. However, the BOD revealed that while S1 denied hurting R1, he confirmed that he did move R1's leg and tap their arm to keep them awake. Report will continue on LIC809-C, 2nd page. Record review revealed that the incident occurred on 07/31/2026. A facility corrective action form dated 08/25/2026, and signed by S1 and the BOD on 08/26/26 indicated that it had been reported on 07/31/26, S1, poked resident in the arm and jerked resident's wheelchair although the resident hadn't moved their feet. S1 was suspended on 08/07/26, pending investigation and later terminated on 08/25/26. Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC809-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.the state’s words, verbatim · CDSS document, Sep 2, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1 · Plan of correction due date: Sep 2, 2026

87468.1(a)(1) Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff...This requirment was not met as evidence by: Based on interviews and record review, the licensee did not comply with the section cited above when staff (S1) poked and jerked R1's wheelchair abruptly which posed a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 2, 2026

Plan of correction: POC has been cleared. S1 received a corrective action and was also terminated.

Type of visit: Required - 1 Year

At 10:10 a.m. Licensing Program Analysts (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by Wellness Director/Designee Lily Duarte and Stephanie Hernandez Business Office Manager and informed them of the reason for the visit. At 10:35 a.m. the LPA, Wellnes Director, and Business Office Manager conducted a tour of the physical plant to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was noted: Facility is a double story residence that consists of Units designated for assisted living residents and memory care residents on both floors. The LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced on 03/02/2026. The smoke alarms and carbon monoxide detectors were tested and were operable. The LPA observed all required postings outside of the dining room. The facility serves residents with dementia. Between 11:30 a.m. and 11:45 a.m., the LPA tested the delay egress on the Exit doors in the courtyard of the Memory Care unit and door leading from Memory Care to Assisted Living and the LPA could not exit unless they knew and entered the code. The LPA attempted to push on both doors over a minute and doors did not open. KITCHEN: Knives and cleaning supplies are stored inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Food is prepared based on the menu. Snacks and beverages are available for residents at the bistro. Report Continued on LIC 809-C BEDROOMS: During today’s visit, the LPA observed 10 (ten) randomly selected resident rooms of which 5 (five) were in Memory Care and 5 (five) were in the AL unit. The resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens. BATHROOMS: The LPA observed 10 (ten) resident bathrooms which were properly supplied and had functional fixtures. The LPA observed grab bars by the toilet/shower and slip-resistant surfaces in all bathrooms. Hot water was measured in all 10 bathrooms, and at 11:48 a.m. the hot water in room 174 was measured at 122.7 degrees Fahrenheit, all other 9 nine restrooms were within the required temperature. Upon observation, water temperature was adjusted in room 174. COMMON AREAS/GROUNDS/OUTDOORS: The common areas were checked for cleanliness and furniture was checked for functionality. The facility maintained a comfortable temperature. There are multiple fireplaces throughout the community, all of which were observed to be adequately screened. There were no obstructions and/or tripping hazards throughout the facility. The LPA observed appropriate outdoor furniture, with covered shaded areas for residents in both memory care units’ courtyards and the assisted living courtyard. RECORD REVIEW: LPA began record review at 2:00PM. Resident records were reviewed for documents including, but not limited to: health screening, TB test, resident physician's report, needs and service appraisal, and personal rights. However, due to time constraint the LPA will return at a later time to complete the annual. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Designee was informed that failure to correct deficiencies may result in civil penalties. Exit interview conducted and copy of the report and appeal rights providedthe state’s words, verbatim · CDSS document, Jul 16, 2026

Allegation investigated: Staff yelled at resident Staff did not comply with infection control requirements Staff did not protect food from contamination Staff did not properly address roaches in the facility Staff did not ensure hazardous items were inaccessible to residents Staff did not allow residents to participate in planned activities Staff did not allow residents to attend religious services

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced initial complaint visit regarding the above noted allegations. 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 and Director of Wellness at 09:47AM, interviewed Memory Care Director at 10:01AM, toured the facility's Memory Care unit with management at 10:25AM, conducted five (5) staff and four (4) resident interviews from 10:36AM to 02:17PM. LPA also reviewed and obtained copies of pertinent documents. The following was then determined: Report Continued on LIC 9099-C (p. 2) Unsubstantiated Allegation “Staff yelled at resident:” The complaint alleges that on 01/01/2026, staff in the facility’s memory care unit was heard yelling at a resident from across the room. Interviews with both staff and residents revealed that the staff are nice and very caring. No staff nor resident interviewed has ever observed any staff being disrespectful, rude, or yelling at any residents. One resident indicated they believe the staff is excellent, friendly, and they care. Management did indicate that particularly in Memory Care, there are some more impulsive residents and that the staff keep a close eye on those residents for their safety. There have been occasions where a resident began to get up and the staff have called the resident’s name in an attempt to get their attention. The staff were trying to get the attention of a particular resident in a positive way, not anything such as yelling or disrespectful tone. 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. Allegation “Staff did not comply with infection control requirements:” The complaint alleges resident wheelchairs are left unsanitary with food and feces and the memory care kitchen area is left unsanitary. During the facility tour, LPA observed the facility kitchen, resident wheelchairs and LPA took photographs. The kitchen area appeared to be relatively clean and the kitchen area is inaccessible to residents in care. The facility does have an infection control plan, which was reviewed with facility staff in December 2025 during the facility’s staff meeting. Interviews revealed the facility is prompt in cleaning up any spills and taking action to ensure the facility remains clean and sanitary. Staff interviewed indicated that the protocol differs, depending on the cleaning and sanitization needed. If a resident is bleeding, the medication technician is called for assistance, and the med tech cleans up the blood before the housekeeping staff sanitize the area. In the case of urine or feces, the care staff will clean the resident and their wheelchair/chair if needed. If there is urine or feces on the floor, housekeeping staff clean and sanitize the floor. 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. Report Continued on LIC 9099-C (p.3) Allegation “Staff did not protect food from contamination:” It was alleged that food is left out uncovered in the Memory Care kitchen area. LPA observed the memory care kitchen during the facility tour and did not observe any food left out on the counters. The facility has warming trays in the memory care kitchen, which were not being utilized at the time of the tour. Staff interviews revealed that food is prepared in the main kitchen area then delivered to the Memory Care unit. One (1) of the memory care staff puts the food into the covered warmers and plates the food for the residents. When residents are done eating, the plates are cleared, food is cleaned up, and the Memory Care staff return the cart, including all dishes and any remaining food, to the main kitchen. LPA observed some food in the refrigerator in the Memory Care unit, which was covered and labeled per regulation. Interview with staff and residents revealed no one has seen food left out in the Memory Care unit. 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. Allegation “Staff did not properly address roaches in the facility:” The complainant indicated roaches were observed in the Memory Care kitchen area, was reported to management, and was not addressed. Interview with staff revealed that there was one (1) person who indicated they saw a roach. Maintenance staff opened all the kitchen cabinets and drawers, looked behind the refrigerator and all other moveable items and did not observe any evidence of an infestation. The facility has a contracted pest control company that provides regular preventative service each month, which was last completed 01/28/2026. As a result of the report made to management regarding an observed roach, the pest company added an additional treatment (roach gel) for the Memory Care kitchen during the recent visit and noted on the report "no activity found inside while performing service." Interview with staff and residents revealed there have been no direct observations nor any evidence of pests in the facility. During today’s facility tour, LPA did not observe any evidence of pest infestation in 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. Report Continued on LIC 9099-C (p. 4) Allegation “Staff did not ensure hazardous items were inaccessible to residents:” The complaint alleges that cleaning supplies and scissors were left accessible to residents in the Memory Care kitchen area and personal items have been left unlocked in resident rooms. During facility tour, LPA noted the Memory Care kitchen has a gate at the entry, which was observed to be latched shut. LPA did observe a pair of scissors in a drawer in the kitchen, but the kitchen area was inaccessible to residents. No cleaning supplies or hazardous personal items were observed accessible during facility tour. Management indicated that all grooming and hygiene items are locked, due to facility policy, but indicated that no residents are at risk if allowed access to these types of items. 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. Allegation “Staff did not allow residents to participate in planned activities:” The complaint alleges that particularly on Sundays and Mondays that the residents in Memory Care (MC) are not offered activities. LPA interviewed the facility’s activity staff for Memory Care, who works Tuesday through Saturday as well as the Memory Care Director who works Sunday through Thursday. Management indicated that when the activity staff is scheduled out, the Memory Care Director assists with activities, as do all care staff. LPA obtained a copy of the Memory Care activity schedule, which shows a variety of activities offered to residents throughout the day every day. There are activities in the Assisted Living (AL) side of the facility that Memory Care staff escort the residents to. Residents interviewed stated there are activities offered to those who choose to engage, but they are never forced to attend activities. Activities include but are not limited to: arts and crafts, exercise, puzzles, games, sing along, and religious services. Management did acknowledge there was a time recently when many Memory Care residents were ill and chose not to participate in the activities offered due to their illness. But typically, many residents do participate and seem to enjoy the activities offered. 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. Report Continued on LIC 9099-C (p. 5) Allegation “Staff did not allow residents to attend religious services:” The complaint alleges that residents are denied mass on Sundays. LPA observed the activity schedule to include Catholic mass scheduled each Friday at 10:00AM. Additionally, there is a church service listed every Sunday at 03:00PM. Residents and staff interviewed indicated all residents in the facility, including those in the Independent Living, Assisted Living, and Memory Care are offered an outdoor church service on Sundays in partnership with Jubilee Church. Interviews revealed that there has never been a time when attending these services was denied. Additionally, residents are free to leave the facility with a family member at any time to attend other religious services of their choosing. 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.the state’s words, verbatim · CDSS document, Feb 3, 2026 · control 29-AS-20260126140448

Allegation investigated: Staff did not assist resident with medical transportation needs

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 and Director of Wellness at 11:40AM, staff at 12:33PM, briefly toured the facility at 12:45PM, conducted two (2) resident interviews from 12:48PM to 03:00PM. LPA also reviewed and obtained copies of pertinent documents. The following was then determined: The complaint alleges that the facility is not providing transportation for Resident #1 (R1)'s scheduled medical appointment. Interview revealed that the facility does have a vehicle and driver available three (3) days a week to take residents to scheduled medical appointments. Staff stated that typically reservations are made a week in advance to secure a spot on one of the available days. In the event a resident becomes ill Report Continued on LIC 9099-C Unsubstantiated and/or has a last minute appointment, the front desk staff will check for availability and add the resident to the schedule if there is availability. In the case of R1, interview revealed that R1's family member called and left a voice message for the concierge at 07:43AM on 01/12/2026 indicating R1 had an appointment scheduled and required transportation. Concierge attempted to return the call, however, R1's family member did not answer nor did R1 or their family member follow up when they were both in the facility speaking to the staff in person. Later that day, police officers arrived at the facility to check on R1. Police informed concierge that R1 had not been assisted with transportation arrangements. Concierge then reached out to R1 via telephone and gathered details about the appointment. Concierge was able to arrange facility transportation for R1's medical appointment scheduled for the next day. Concierge did receive a call back from R1's family member on the morning of 01/13/2026 and informed them of the transportation arrangements. Interview with R1 confirmed the facility driver did assist R1 in their transportation needs and took R1 to their appointment. 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.the state’s words, verbatim · CDSS document, Jan 14, 2026 · control 29-AS-20260112122927

Allegation investigated: Staff are mishandling a resident's medication

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 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.the state’s words, verbatim · CDSS document, Dec 2, 2025 · control 29-AS-20251130231129

Type of visit: Prelicensing

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) (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) (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.the state’s words, verbatim · CDSS document, May 8, 2025