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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803756
Report Date: 07/14/2022
Date Signed: 07/15/2022 06:54:17 AM

Document Has Been Signed on 07/15/2022 06:54 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:CYPRESS HOMEFACILITY NUMBER:
216803756
ADMINISTRATOR:ROJAS, MONAFACILITY TYPE:
735
ADDRESS:856 CYPRESS AVETELEPHONE:
(415) 895-1399
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 4CENSUS: 4DATE:
07/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Ivy Payumo - staffTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility was welcome by staff Arturo SanJuan. Staff contacted administrator Mona Rojas who spoke on the phone with LPA during this visit. Clients were present during the visit. There is no day program at this time due to short staffing at ADP (Adult Day Program). There are activities planned for clients during the day if they want to participate and outings.

LPA arrived at the facility and observed a check in for staff and visitor’s by the entrance door. During facility tour on 7/14/2022 with staff Ivy Payumo, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Sample of client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 10/2021 at the time of the visit. Carbon monoxide detector and sample smoke detectors test was conducted and were operational during this visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored locked under kitchen sink. LPA observed that dangerous items were locked. There was a supply of cleaners, hygiene products and paper products available for clients. Sample of client’s bedrooms were inspected and had lighting & appropriate furnishings; mattress pads are available for clients at the facility. Facility hot water temperature in clients' bathroom faucet measured between 117.8 degrees F and 120 degrees F in 2 out of 2 faucets within Title 22 acceptable regulations of 105 to 120 degrees F. Disaster Drills have been conducted monthly and last dated 6/25/22.

In addition, Department is requesting an updated LIC 602 for client C1 due to a change of condition and client C2 due to concerns regarding ambulatory status by July 21, 2022.

Continued LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CYPRESS HOME
FACILITY NUMBER: 216803756
VISIT DATE: 07/14/2022
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Infection Control:
Facility has submitted a COVID-19 mitigation program plan that has been approved and infection control plan has been submitted. Posters have been placed at facility, container with hand sanitizer and other items designated for visitors and staff are at entrance. Staff before coming into work has temperature checked. Facility has some PPE supply stored in the facility garage area. Clients’ medications are stored and locked in medication medical cart in the dining area. Facility has a 30-day supply of medication for clients. Clients are sometimes wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. Staff had masks on during this visit. Facility is allowing visitors and clients have available virtual and telephone calls when contacting with family members and others. Per administrator all PPE training required is on file and all staff has acquired N-95 fit testing.

There were no deficiencies cited at this time.

Department is requesting Licensee to update the following documents and submit to CCL by 07/21/2022:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 400 Affidavit Regarding Resident Cash Resources
LIC 402 Surety Bond (if applicable)
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Current Administrator's Certificate
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
LIC809 (FAS) - (06/04)
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