Cypress Residence

Allegation investigated: Staff do not ensure resident is turned/rotated resulting in resident sustaining pressure injuries.

At approximately 9:00 AM on 11.19.2025, Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an unannounced, subsequent complaint visit. LPA met with staff and disclosed the reason for the visit. To investigate the allegation above, LPA conducted an initial visit on 5.21.2025 and toured the facility inside and out at 9:05AM. LPA interviewed staff, residents, and their family members between 10:44 AM and 2:00 PM. LPA conducted a record review of pertinent records, including but not limited to a physician report, admission agreement, appraisal needs and service plan, hospital discharge after visit summary (AVS), and other pertinent records at 2:00 PM. Copies records requested and received at 2:45PM. Today, LPA toured the facility at 9:45 AM. Regarding the allegation “Staff do not ensure resident is turned/rotated, resulting in resident sustaining pressure injuries,” Continue to LIC 9099-C Substantiated It was alleged that on 5/11/2025 resident #1 (R1) was admitted to the hospital. Upon admission it was found that R1 had 4 pressure injuries on his upper and lower back. It was reported that R1 sits in a recliner most of the day or is in bed, No turning assistance was provided to avoid or relief pressure injuries. During LPA visit on 5.21.2025, it was observed that the staff continued to care for R1 at the facility. The interview with the administrator and staff at 10:44 AM revealed that staff were instructed to reposition R1 every two (02) hours. Interview with Staff #1 (S3) at 11:00 AM on 5.16.2025 confirmed that all staff had been trained by a vendor for R1’s care. LPA observed staff repositioned R1 every two (02) hours, assisted with incontinence care, and ensured their wounds were dry and free of redness. LPA interviewed R1 at 12:00 PM and stated that staff constantly check, reposition, and transfer them to their chair recliner/ bed from time to time. Interviews with five (5) out of six (6) other residents interviewed revealed they have no issues with pressure injuries. An interview with R1 family revealed that they are happy with the care given by the facility and were not aware that R1 should be at a higher level of care. A review of R1’s initial assessment revealed they had no history or signs of skin breakdown as of 11.20.2024 during admission. LPA reviewed R1 medical documents revealed that R1 was admitted to the ER on 4.22.2025 and on 5.12.2025 for other health concerns. On 4.22.2025, a stage 3 pressure injury was already observed on the thoracic (back) region. Then on 5.12.2025 at the time of admission to the hospital, the following pressure injuries were observed; sacral stage 3, extending to the right (R) buttock; Right (R) Thoracic- Unstageable; Medial Location Thoracic- Unstageable; Left hip Deep Tissue Injury (DTI) Stage 3. R1 was discharged and returned to the facility with home health (HH) wound care on 5.16.2025. Overall investigation revealed that R1 developed prohibited health condition (Stage 3 Pressure injuries) while in care of the facility. Although R1 was receiving home health care services for a wound care and staff was providing required assistance, between 04.22.25 and 05.22.25, pressure injuries were not healing. After both hospitalization R1 was readmitted to the facility with stage 3 pressure injuries, which was requiring higher level of care. Therefore, based on inspection, observation, interviews and record review, the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on the LIC 9099-D page .An immediate civil penalty of $500.00 was issued for continuing to retain and readmit R1 to the facility with prohibited health condition which requires higher level of care. The Administrator was informed that additional civil penalties will be issued under Health & Safety Code 1569.49(f). Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Nov 19, 2025 · control 31-AS-20250514110207

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Nov 20, 2025

Prohibited Health Condition: Persons who require health services for or have a health condition, including, but not limited to, Stage 3 and 4 pressure injuries, shall not be admitted or retained in a residential care facility for the elderly. This requirement was not met, as evidenced by medical records received and interviews with home health staff conducted by IB, confirming R1 sustaining multiple stage 3 wounds.the state’s words, verbatim · CDSS document, Nov 19, 2025

Plan of correction: As POC, within 24 hours, the administrator will provide written plan of action explaining steps they will take to avoid similar issues from happening again. Written statement should verify that a Licensed consultant will be hired to provide additional training to address this section of the regulation. A copy of the training log, the training topic, and attendance shall be submitted to the Licensing agency by 11.20.2025.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Abeye Duguma met with Ligaya Valenzuela for a Required One (01) Year visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at around 10:30 AM and the following was noted: There is one entrance being utilized at the facility. The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water. The garage is currently being used for storage. The facility has a total of four (04) bedrooms and two (02) bathrooms. The facility is fire cleared for six (06) non-ambulatory. The facility is currently occupying six (06) residents. Kitchen is sufficiently stocked with at least two (02) days perishable and seven (07) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents. The living and dining room are neat and clean. The facility maintains a comfortable temperature at 77°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguisher is located near the kitchen, observed to be fully charged and last inspected on 06/05/2025. (continued on LIC 809-C) The residents' rooms are adequately furnished with appropriate lighting system. Hallways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 113.7°F. Towels and washcloths are not shared. There was enough clean linen available in the cabinets. Laundry detergents, cleaning agents and other toxins are locked away. LPA observed medication to be locked and inaccessible to residents. Facility maintains a complete first aid kit. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Oct 9, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Abeye Duguma met with Ligaya Valenzuela for a Required One (01) Year visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at around 1:45 PM and the following was noted: There is one entrance being utilized at the facility. The facility has a total of four (04) bedrooms and two (02) bathrooms. The facility is fire cleared for six (06) non-ambulatory. The facility is currently occupying five (05) residents. The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water. The garage is currently being used for storage. Laundry detergents, cleaning agents and other toxins are locked away. Kitchen is sufficiently stocked with at least two (02) days perishable and seven (07) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents. The living and dining room are neat and clean. The facility maintains a comfortable temperature at 76°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguisher is located near the kitchen, observed to be fully charged and last inspected on 06/03/2024. (continued on LIC 809-C) The residents' rooms are adequately furnished with appropriate lighting system. Hallways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 117.2°F. Towels and washcloths are not shared. There was enough clean linen available in the cabinets. LPA observed medication to be locked and inaccessible to residents. Facility maintains a complete first aid kit. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Oct 4, 2024