<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005857
Report Date: 09/28/2021
Date Signed: 10/05/2021 09:56:59 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/05/2021 09:56 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CK HOMES/ CYPRESS 1FACILITY NUMBER:
306005857
ADMINISTRATOR:KNIAZEFF, MAXINEFACILITY TYPE:
735
ADDRESS:8732 CYPRESS AVE.TELEPHONE:
(714) 488-2493
CITY:CYPRESSSTATE: CAZIP CODE:
90630
CAPACITY: 6CENSUS: 6DATE:
09/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:03 AM
MET WITH:Care staff Adelardo AbadTIME COMPLETED:
01:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Shobhana Frank made unannounced visit to the facility for the purpose of conducting an Annual Required Inspection. LPA Frank arrived at the facility and met with Care staff Adelardo Abad and explained the reason for the visit.

LPA Frank toured the facility with care staff Adelardo which included: The Facility is a single story house the houses is newly build, with total 7 bedrooms, 6 private bedrooms for the residents, 1 medication room, 2 full bathrooms, a living room, activity room, dining area, and kitchen, reviewed medications; medication records, food service, clients and staff records
The following was observed:
The facility is a one story house which is Licensed for Adult Residents six ambulatory clients Ages 18 to 59 Years. Currently 6 clients are in care. Each resident bedroom is equipped with the proper furniture and linen supplies.
LPA observed COVID - station equipped with hand sanitizer, thermometer, Gloves, visitors log. LPA observed COVID posters throughout the facility.
LPA observed Facility’s physical plant, hallways appears to be clean and free of debris, free of odor. Sufficient lighting observed throughout the facility. No bodies of water, weapons or ammunition on premises. Smoke detectors and carbon monoxide detector were tested and are operational. Fire extinguishers were fully charged. Facility stove, oven, microwave, refrigerator, washer and dryer are clean and operational.
LPA observed 2-day supply of Non-perishable and 7-day supply of perishables food available in the kitchen and refrigerator. Facility refrigerator, frizzier and canned food were inspected. All canned food noted to be within expired date. LPA observed plenty of fresh fruits, vegetable and water available for clients. Meal menus were posted. Kitchen area was free of potential hazards and appeared to be meet sanitary regulations. LPA observed emergency supplies packaged. Comfortable temperature was maintained in the facility; Water temperature was measured at 119.6 degrees Fahrenheit.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Shobhana Frank
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2021
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CK HOMES/ CYPRESS 1
FACILITY NUMBER: 306005857
VISIT DATE: 09/28/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA reviewed two clients record- current Physicians Report, IPP, PNI, Identification and Emergency Information, Admission Agreement, Centrally Stored Medication and Destruction Record in each resident's file. Medications were secured in locked cabinets. LPA was able to verify that medication containers were being administered by physician's orders.
LPA reviewed two staff records and verified that all staff have a current First Aid training certificate, Criminal record statement, Personnel Record, TB clearance, and Health Screening Report in their file. staff training are current, medication management ;consumer personal rights, sign and symptoms of illness or injury; Safeguarding of cash resources; Abuse report procedures; First Aid/CPR certificates are current.
Administrator Certificate is current. Administrator on the premise for at least 40 hours a week to oversee the business operation and ensure quality care is being provided.
LPA reviewed staff files, clients files and LIC 610 emergency disaster plan, LIC 808 mitigation plan, client roster, staff schedule LIC 500, LIC 308 and all paperwork were well organized.
Based on the observations made during today's visit, no deficiencies were observed in the area inspected.
LPA discussed this report with the Administrator Maxine Kniazeff. A copy of this report was provided.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Shobhana Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2