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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803756
Report Date: 09/20/2024
Date Signed: 09/20/2024 11:54:35 AM

Document Has Been Signed on 09/20/2024 11:54 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:CYPRESS HOMEFACILITY NUMBER:
216803756
ADMINISTRATOR/
DIRECTOR:		ROJAS, MONAFACILITY TYPE:
735
ADDRESS:856 CYPRESS AVETELEPHONE:
(415) 895-1399
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 4CENSUS: 4DATE:
09/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:09 AM
MET WITH:CaregiverTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Administrator Mona Rojas was not available to come to the facility but was available via phone. Admin gave caregiver (S1) permission to sign report. Facility contact information was reviewed.

At approximately 9:15am LPA and caregiver toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Kitchen cabinet containing cleaning supplies was locked. Kitchen drawer with sharp knives locked.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 116.4 degree F in the kitchen, 111 degrees F in the main bathroom and 113.3 degrees F in the shower room which all are within the allowable range of 105 to 120 degrees F.

Fire extinguishers were last inspected 5/23/2024. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drills were conducted 9/9/24.

At approximately 9:45am LPA conducted review of 5 staff records. All required documentation present.

At approximately 10:30am LPA conducted a review of 4 resident records. All required documentation present. 1/2 rails and hospital bed orders all on file for respective residents.

Continued on 809C...

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CYPRESS HOME
FACILITY NUMBER: 216803756
VISIT DATE: 09/20/2024
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Continued from 809...

At approximately 11:30pm LPA and caregiver conducted a spot check of medication and medication records. Medication is centrally stored in a locked medication cart. No deficiencies

Mona Rojas Administrator Certificate 7003568735 expires 1/18/2025. All fees are current as of this time.



Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
LIC400 Cash affidavit
Surety Bond

No deficiencies cited.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024
LIC809 (FAS) - (06/04)
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