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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005857
Report Date: 08/16/2024
Date Signed: 08/16/2024 04:43:24 PM

Document Has Been Signed on 08/16/2024 04:43 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CK HOMES/ CYPRESS 1FACILITY NUMBER:
306005857
ADMINISTRATOR/
DIRECTOR:		KNIAZEFF, MAXINEFACILITY TYPE:
735
ADDRESS:8732 CYPRESS AVE.TELEPHONE:
(714) 488-2493
CITY:CYPRESSSTATE: CAZIP CODE:
90630
CAPACITY: 6CENSUS: 4DATE:
08/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Maxine KniazeffTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by DSP staff, Relea De Castro. Administrator (AD) Maxine Kniazeff and Assistant Administrator (AA) Shirley Kniazeff arrived shortly afterwards to assist with today’s visit. The facility is licensed for 6 ambulatory clients. Currently there are 4 clients living here during today's visit.

At 1:50 PM, LPA Tea reviewed four client files and two staff files. Client files and staff files contained all required documentation. The administrator certificate expires on July 28, 2026, but administrator has yet to physically receive her new certificate due to the department back log in processing administrator certificates.



LPA Tea along with lead staff Adelardo Abad toured the facility at 2:55 PM. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a one-story home with six client bedrooms and two bathrooms. The facility has a kitchen, dining room, living room and a garage. There is also a room to administer and store medication and first aid supplies, and emergency supplies, food and water are stored there as well. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each client comfortably. Client bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Water temperature measured between 110.6 F degrees and 111.5 F degrees. Client bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including bandages, tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked in a kitchen cabinet. LPA also observed toxin substances to be secured and locked and inaccessible to clients underneath the sink and in a storage closet by the laundry area.

Continuation of annual report on LIC809C

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CK HOMES/ CYPRESS 1
FACILITY NUMBER: 306005857
VISIT DATE: 08/16/2024
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The fire extinguisher in the living room area is fully charged. The facility’s last fire drill was conducted on August 05, 2024. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating with shade in the garage. In the garage they do activities and games. There is a basketball hoop for them to play basketball outside. LPA Tea observed clients returning from their day programs, some are enjoying their snacks, some clients are relaxing and singing. The staff provide activities based on client’s personal preference such as puzzles and art coloring. There is a daily activity calendar in the hallway. Occasionally they would go out for walks, and staff take them to outings such as going to church.

At 3:11 PM LPA reviewed medication storage and administration. Medications are stored securely in the medication room. Medications are being administered per physician order. P&I Funds were checked and meet department standards. LPA interviewed clients regarding their quality of care and spoke to staff present regarding care provided.



Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with AD Maxine Kniazeff AA Shirley Kniazeff and a copy of this report LIC809, 809-C, LIC858, and LIC859 was read and provided to the facility
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
LIC809 (FAS) - (06/04)
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