306005908-12-3-2021-22-AS-SFRK-C9D3N6-20211203172326

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005908
Report Date: 12/03/2021
Date Signed: 12/03/2021 05:24:20 PM

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:	WESTMONT OF CYPRESS		FACILITY NUMBER:	306005908
ADMINISTRATOR:	HENDERSON, ROBERT		FACILITY TYPE:	740
ADDRESS:	4889 & 4775 KATELLA AVE.		TELEPHONE:	(858) 729-6720
CITY:	CYPRESS	STATE: CA	ZIP CODE:	90720
CAPACITY:	152	CENSUS: 0	DATE:	12/03/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:41 AM
MET WITH:	Exicutive Director Samuel Feya		TIME COMPLETED:	01:35 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 Analysts (LPA) Shobhana Frank conducted an announced visit for the purpose of a Pre-Licensing inspection and COMP III. LPA Frank was greeted and granted entry to the facility by Executive Director Sam Faye. An initial application to operate a Residential Care Facility for the Elderly was submitted to the Central Applications Unit (CAU) on 7/21/2021 for a capacity of 152 Non-ambulatory residents. LPA Frank toured the facility along with Executive Director Sam Faye. During today's inspection visit, LPA observed the following: Facility is a two buildings one # 4775 two story Memory care and second # 4889 is Assisted living three story building, 99 apartments in the assisted living and 34 apartments in the memory care unit, total 152 capacity. Facility offers a beauty salon, media room, gym, activity area several dining areas as well as outside patio areas. Living Room/ Dining Room: Adequate seating is available in the main dining room and visiting areas. Bedrooms Residents: All rooms are equipped with appropriate lighting, chair, night stand and ample closet space. Rooms contain a mini kitchen area complete with a mini fridge. Bathrooms: All resident bathrooms have a working toilet/ wash basin as well as grab bars and non-skid surface in the shower and washer/dryer. Emergency Phone Numbers and Exit Plan Posted in entrance of facility. Facility has ample perishable and non perishable food supplies. All equipment is tested for temperature and are within acceptable ranges. LPA observed a posted menu with multiple choices for residents. Fire extinguishers were mounted and charged. Smoke detectors were centrally wired throughout and have been checked by the fire department. The facility has dual smoke detectors and carbon monoxide detectors throughout the building. There was one E-Vacs chairs near each stairwells at the facility. There were two locked medication rooms on the first floor( one in memory care and one is Assisted Living). Both medication rooms store first aid kits. There is a large storage of toxins and cleaning equipment. An emergency call system was in place in each apartment unit. A fire clearance was granted on 11/17/2021. The kitchen area was checked. There were emergency food supplies and water. LPA observed activity calendars, theft and loss policy, admission agreement, resident rights and emergency plans were posted.

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Shobhana Frank	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021

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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: WESTMONT OF CYPRESS	FACILITY NUMBER: 306005908
	VISIT DATE: 12/03/2021

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including the Ombudsman and Let Us Know poster. The Memory Care unit has their own activity room/ living room area and dining area. LPA reviewed the outdoor area and observed a covered patio structure and outdoor furniture in the memory care and Assisted Living.
Component III was conducted with Sam Faye, ED.

It appears that this facility meets the requirements for licensure.
Licensure was informed today that the facility is ready for licensure and final approval will be processed by the CAU supervisor in Sacramento. An exit interview was conducted with Licensure and copy of report was provided.

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Shobhana Frank	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021

LIC809 (FAS) - (06/04)

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