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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803756
Report Date: 07/11/2023
Date Signed: 07/11/2023 01:58:11 PM

Document Has Been Signed on 07/11/2023 01:58 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
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:
07/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:51 AM
MET WITH:Mary Galang (House Manager)TIME COMPLETED:
02:13 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with House Manager Mary Galang. Administrator Mona Rojas arrived later. Clients were present participating in activities.

LPA initiated a tour of the facility and made the following observations: Facility was a comfortable temperature and pathways were free from obstructions. Client rooms are furnished per regulation. Water temperatures in client bathrooms read at 113.4 and 117 which is within regulation of 105 and 120 degrees F. At least two days of perishable and one week of non-perishable foods were available. Toxins are locked in a cabinet. Medications are centrally stored in locked cabinet and medication records were reviewed. Fire extinguishers were last inspected October 2022. Smoke detectors and carbon monoxide detector are wired located throughout the facility were tested and operational. Most recent Fire/Disaster drill was conducted July 10, 2023. Facility does have a current activity calendar and menu. Required postings were observed. First aid kit was fully stocked.

At 12:30pm LPA conducted a file review of four client and five staff files. Clients records have updated care plans on file. CPR/1st aid certificates and training hours are current. Administrator Certificate for Mona Rojas 6012770735 expires 1/18/25. Cash resources and documentation were reviewed.

LPA obtained updates of the following documents: LIC500 (Personnel Report), LIC308 (Designation of facility responsibility), Surety bond, LIC400 (cash affidavit for clients) and lease agreement.

No deficiencies cited during today's inspection.
Exit interview conducted with House Manager and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2023
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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