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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850555
Report Date: 09/02/2026
Date Signed: 09/02/2026 05:24:28 PM

Document Has Been Signed on 09/02/2026 05:24 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 LIVINGFACILITY NUMBER:
565850555
ADMINISTRATOR/
DIRECTOR:		ROZANER, GINAFACILITY TYPE:
740
ADDRESS:1200 CYPRESS POINT LANETELEPHONE:
(805) 650-6000
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY: 89CENSUS: 78DATE:
09/02/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:20 PM
MET WITH:Ken Mahler-Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
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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.
Kasandra Lopez
Esther Cortez
DATE: 09/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2026
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: 09/02/2026
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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.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/02/2026 05:24 PM - It Cannot Be Edited


Created By: Esther Cortez On 09/02/2026 at 05:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CYPRESS PLACE ASSISTED LIVING
FACILITY NUMBER: 565850555

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/02/2026
Section Cited
CCR
87468.1

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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:
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POC has been cleared. S1 received a corrective action and was also terminated.
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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.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Esther Cortez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2026


LIC809 (FAS) - (06/04)
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