Cypress Court Escondido

Type of visit: Required - 1 Year

On 8/3/26, Licensing Program Analyst (LPA) Kyle Wellington arrived unannounced to conduct an annual inspection. LPA met with Executive Director (ED), Tania Dupre, who was informed of the purpose of the visit. LPA received a staff roster and resident roster from ED. There were 87 staff members and 164 residents at the facility. Facility has a fire clearance for 293 non-ambulatory residents where three (3) can be bedridden in rooms 124, 144, 228, 230, 238, or 240. Facility was granted a hospice waiver for ten (10) residents. LPA toured the inside and outside of the facility with Business Office Manager (BOM), Collette Escalante. LPA conducted an observation and record review for the inspection. Facility Overview: Facility is a four story building for assisted living residents. Front desk, administrative offices and a parking garage were on the ground floor. Kitchen, dining room, mail room, chapel, library, activity room, art studio, salon, family room and common areas were on the 1st floor. A gym was on the 2nd floor. There are no pools or bodies of water at the facility. Infection Control: LPA observed hand sanitizers and soap dispensers throughout the facility. Cleaning equipment and cleaning supplies were kept in locked rooms on each floor available for regular facility maintenance. LPA reviewed the facility’s infection control plan which met the department’s requirements. Physical Plant: LPA observed the inside and outside of the facility to be clean, safe and well kept. The floors, windows and doors were clean and well maintained. The furniture was in good repair. Bedrooms had the required lighting and furniture. Bathrooms had grab bars and non-slip floors in the showers. Incontinence and cleaning supplies were kept in locked rooms on each floor inaccessible to residents. There were two (2) laundry rooms on each floor except the 4th floor which has one (1) laundry room. Laundry equipment appeared to be in good working condition. There was a central outdoor area that contained outdoor furniture and shaded areas for residents. Indoor and outdoor passageways along with entrances and exits were free of obstructions. Safety: There were fire alarm systems, carbon monoxide detectors, and charged fire extinguishers throughout the facility. The fire extinguisher service tags noted the fire extinguishers were last serviced on 1/29/26 which was within the last year. The facility's last fire safety inspection was performed by Western Fire in 1/26. The facility's last fire drill was last performed by LTC Safety on 6/24/26. Kitchen/Food Service: LPA observed the kitchen to be clean, organized, and well maintained. The kitchen had the ability to prepare and store food in a safe and clean environment. Kitchen appliances appeared to be in good working condition. Dishes and utensils were in sufficient supply and stored properly. Sharp objects were put away correctly. Perishable and non-perishable foods were not expired. There was over a two day supply of perishable foods and over a seven day supply of non-perishable foods. Care & Supervision: Facility has sufficient staff to supervise the residents and operate the facility. LPA observed med techs, caregivers, servers and housekeeping/laundry/kitchen/maintenance staff at the facility. Administration: LPA observed emergency exit information, emergency/disaster plans with emergency phone numbers, personal rights, complaint procedures and long-term care ombudsman information posted at the facility. ED holds a current Administrator Certificate and a Criminal Record Clearance. Record Review and Resident/Staff Files: LPA reviewed the records of five (5) resident files and five (5) staff files. Staff have criminal record clearance and are associated with the facility. The files contained all the required documentation and paperwork. The staff and client files were kept locked away inaccessible to unauthorized individuals. Health Related Services/Incidental Medical Services: LPA observed clients' medications were centrally stored and secured in med cabinets in the Med Room inaccessible to residents. First aid kit was kept in the locked Med Room inaccessible to residents. No deficiencies were cited during this visit. An exit interview was conducted with the Executive Director, Tania Dupre and a copy of this report was given to Executive Director, Tania Dupree.the state’s words, verbatim · CDSS document, Aug 3, 2026

Type of visit: Case Management - Health Checks

On 02/23/2026, Licensing Program Analyst (LPA) Janette Romero made an unannounced visit to the facility to conduct a health and safety visit to follow up on a Report of Suspected Dependent Adult/Elder Abuse (SOC 341) submitted by Administrator Tania Dupre reporting an alleged incident between Resident 1 (R1) and Staff 1 (S1). The SOC 341 notes the following. On 01/14/2026, staff reported to Administrator Dupre that S1 alleged that R1 paid them to perform sexual acts for R1. Administrator Dupre collected written statements from staff and spoke with R1 who refuted the allegation and denied any favors being asked for or performed. S1 has been on a leave of absence since 01/13/2026 and Administrator Dupre was unable to make contact with them for a statement. During today's visit, LPA met with Administrator Dupre who was informed of the purpose of the visit. LPA toured the facility, conducted interviews, and obtained copies of pertinent documentation. Administrator Dupre was interviewed and reported they have since made contact with S1 who denied ever making such allegation. Administrator Dupre reported there are no reports of any possible additional victims, a specific incident date/time-frame, or any evidence to indicate the allegation is true. Administrator Dupre reported at this time, S1 has not been scheduled to return to work in the facility. LPA conducted an interview with R1 who denied the allegation. R1 reported they do not have a personal/romantic relationship with S1 and S1 has always behaved in a professional manner. No immediate health or safety concerns were observed during today's visit. No deficiencies were cited and the SOC 341 was submitted to Community Care Licensing in a timely manner. An exit interview was conducted and a copy of this report and Confidential Names list (LIC 811) was reviewed and provided to Administrator Dupre.the state’s words, verbatim · CDSS document, Feb 23, 2026

Allegation investigated: Facility roof is in disrepair

On 11/25/2024, Licensing Program Analyst (LPA), Janette Romero made an unannounced visit to investigate the allegation listed above. LPA met with Administrator, Tania Dupre who was informed of the purpose of the visit. It was alleged there are various leaks in the roof throughout the facility affecting resident rooms, the dining room, and hallways. LPA conducted a tour of the interior of the facility with Administrator Dupre and at the time of the visit there was no active leaks observed. However, it was not observed to be raining outside. Administrator Dupre and Maintenance Director, Ismael Damian identified the areas and resident rooms that have been affected by the leaks in the roof. Administrator Dupre stated that the roof was previously repaired, however some leaks are still present and the roof is scheduled to be repaired in 2025. LPA reviewed the facility's 2023 Roof Survey dated 6/27/2023 providing an estimate for several roof repairs/maintenance actions recommended to be completed immediately. LPA observed the hallway near room 357 with brown spots in the ceiling where Administrator Dupre identified to have knowledge of water leaking in 2023. Substantiated Four (4) residents were interviewed and all reported to have knowledge of water leaking in the dining room during 2023's rainy season. LPA toured the bedroom shared by Resident 1 (R1) and Resident 2 (R2) and observed what appeared to be a plastic grocery bag taped to the ceiling directly above R1 and R2's bed. R1 and R2 were interviewed and reported water has been leaking through the fire sprinkler for the past three (3) years anytime it rains heavily. R1 and R2 reported Staff 1 (S1) placed the plastic grocery plastic bag over the fire sprinkler to contain the leaking water. S1 was interviewed and confirmed taping the bag to the bedroom ceiling of the room shared by R1 and R2 in order to temporarily contain the leaking water to avoid it from landing on R1 and R2's bed. Administrator Dupre reported they were unaware facility staff taped the plastic grocery bag to R1 and R2's bedroom ceiling as a temporary solution. Administrator Dupre stated they will have a contractor repair the ceiling in R1 and R2's bedroom by 12/9/2024. Based on LPA’s observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations (Title 22, Division 6, Chapter 9), are being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided to Administrator Dupre along with the Confidential Names list (LIC 811) and Appeal Rights.the state’s words, verbatim · CDSS document, Nov 25, 2024 · control 18-AS-20241121150339

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Dec 9, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. Based on observations, interviews conducted, and record review the facility roof is in disrepair as water continues to leak throughout different areas of the facility, including R1 and R2's room. This poses a potential health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 25, 2024

Plan of correction: Licensee reported they will have a contractor repair the ceiling in the bedroom shared by R1 and R2 and provide proof of correction to LPA by close of business on POC due date. Licensee added they will ensure

Type of visit: Case Management - Deficiencies

On 11/25/2024, Licensing Program Analyst (LPA), Janette Romero conducted an unannounced case management visit to address a deficiency observed during a complaint investigation. LPA met with Administrator, Tania Dupre and Business Office Manager, Collette Escalante who were informed of the purpose of the visit. During a record review, LPA observed the facility has not paid their annual licensing fees due on 7/12/2024 and has a current balance of $4,455.00. The facility will be cited. An exit interview was conducted and a copy of this report was reviewed and provided to Administrator Dupre along with an LIC 809-D and Appeal Rights.the state’s words, verbatim · CDSS document, Nov 25, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87156(a) · Plan of correction due date: Dec 9, 2024

87156 Licensing Fees (a) An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185. During a record review, LPA observed the facility has not paid their annual licensing fees due on 7/12/2024 and has a current balance of $4,455.00. This poses a potential health or safety risk to clients in care.the state’s words, verbatim · CDSS document, Nov 25, 2024

Plan of correction: Licensee reported they will pay their licensing fees and provide proof of correction to LPA by close of business on POC due date.

Type of visit: Required - 1 Year

On July 25, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the Required Annual Inspection and met with the Administrator, Tania Dupre. The facility file review was conducted at the Regional Office and additional forms were requested and reviewed on site. The facility is licensed for 293 Elderly Adults and is currently operating at a capacity of 161 Older Adults (740). LPA Mixson toured the facility, and inspected the facility inside and outside. There were no obstructions or debris to the indoor or outdoor passageways at the time of this visit. The facility has several levels for a total of four on one side and three floors on the other side of the building, and is located at 1255 N. Broadway Escondido, CA 92026. Physical Plant: The facility phone number is (760) 747-1940 and is operable. LPA Mixson observed a sample the residents’ living units, and each was equipped with required furniture as per Title 22. LPA Mixson inspected a sample of the facility restrooms on the first and second floors, and the hot water temperature tested within regulations. The bathrooms were clean, and appliances were operating appropriately, and there was liquid soap and paper towels currently at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. LPA Mixson observed required postings such as "If you See Something, Say Something" the "Personal Rights," along with the Ombudsman. The cleaning supplies and sharp items were kept locked and inaccessible to the residents in care. There was a designated storage space for the residents and staff files, and it was locked and inaccessible to residents in care currently at the time of this visit. Medications: Were locked and inaccessible to residents in care, and there was a sufficient supply of medication for each resident. There was a Wellness Center and/or Nurses station and it was lockable. The facility cooling system and other appliances were operable currently at the time of this visit. LPA was informed by the Administrator that there were safety lights for night throughout the facility. CONTINUE ON NEXT PAGE CONTINUED FROM LIC-809 Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Dishes and utensils were in sufficient supply and stored properly, and sharp items are locked. Care & Supervision: Facility has sufficient staff on site at the time of this visit. Receptionist at the front desk, maintenance team, and house keeping teams were observed on each floor. Nurses and other care staff were in sufficient numbers for this facility type. Records Review: LPA Mixson reviewed resident and staff files, conducted resident and staff interviews, and reviewed previous Community Care Licensing forms. There were no Title 22, Division 6 Regulation violations observed or cited during today’s visit. An exit interview was conducted, and a copy of this report was discussed and provided to Administrator, Tania Dupre.the state’s words, verbatim · CDSS document, Jul 25, 2024

Allegation investigated: Facility staff did not follow resident's care agreement. Facility staff did not follow physician's orders.

Licensing Program Analyst (LPA) Mark Mandel conducted an unannounced visit to follow-up on a complaint investigation regarding the above-mentioned allegations. LPA identified himself and was granted entry by and met with Administrator, Tania Dupre. LPA stated the purpose of the visit and discussed the elements of the complaint with Administrtor, Tania Dupre. LPA delivered the investigative findings to Ms. Dupre . On 08/18/2020, the Department received a complaint alleging that facility staff did not follow Resident 1's (R1) (see LIC 811 Confidential Names List) care agreement and did not follow R1's physician's orders. The Department’s investigation consisted of a facility visit, staff interview and records review. (Cont. on LIC9099-C) Unsubstantiated (Cont. from LIC 9099) It was alleged that the facility staff did not follow R1's care agreement on 08/17/20 by taking her to the emergency room before contacting the Power of Attorney for R1. Staff 1 (S1) stated that a new property manager took over the facility and moved records prior to 2021 off site, which would include resident care records pertaining to the alleged incident that occurred on 08/17/20. In accordance with Title 22 regulations, facilities are are only required to keep facility records for three years. No additional records or other relevant information from outside sources was provided to support this allegation. It was also alleged that the facility staff did not follow R1's physician's orders by continuing to administer a prescribed medication, Donepezil, to R1 from, on or about, 05/20/2019, until, on or about, 11/21/2019. S1 stated that a new property manager took over the facility and moved records prior to 2021 off site, which would include medication administration records pertaining to the allegation. In accordance with Title 22 regulations, facilities are only required to keep facility records for three years. No additional records or other relevant information from outside sources was provided to support this allegation. Based on the evidence reviewed, the allegations that facility staff did not follow R1's care agreement and did not follow R1's physician's orders are Unsubstantiated, as the preponderance of evidence standard was not met. An exit interview was conducted with Administrator, Tania Dupre, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).the state’s words, verbatim · CDSS document, Dec 14, 2023 · control 08-AS-20200818154152