306005971-6-9-2026-22-AS-JHAY-DUVVFV-20260609162431

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005971
Report Date: 06/09/2026
Date Signed: 06/09/2026 04:25:05 PM

Document Has Been Signed on 06/09/2026 04:25 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 II		FACILITY NUMBER:	306005971
ADMINISTRATOR/ DIRECTOR:	KNIAZEFF, MAXINE		FACILITY TYPE:	740
ADDRESS:	8742 CYPRESS AVE.		TELEPHONE:	(714) 488-2493
CITY:	CYPRESS	STATE: CA	ZIP CODE:	90630
CAPACITY: 6		CENSUS: 3	DATE:	06/09/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	07:40 AM
MET WITH:	Maxine Kniazeff		TIME VISIT/ INSPECTION COMPLETED:	10:40 AM

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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one-year annual inspection. LPA was greeted, granted entry by staff and explained the reason for the visit.

Structure:

The facility is a single level structure and licensed for six ambulatory residents, As of today, the facility has three residents admitted. All residents were present upon LPA’s arrival and then left for their day program. There’s a total of 6 bedrooms of which 4 bedrooms are for the residents and two bedrooms have been converted into activity areas. There are two restrooms available. There’s a living room space, a dining space and an attached garage. Bedrooms: All bedrooms have the required furnishings: bed, lamp, chair, and storage space. Bathroom(s): Bathrooms are equipped with a working toilet, wash basin, and shower. Hot water measured in between 116.2 – 116.6 degrees F. Kitchen: All burners and the warmer were operational on the gas stove. Sharps are kept locked cabinet near the stove. Dish soaps and cleaning chemicals are stored below the sink. Food Service: A supply of perishable and non-perishable food items that meet regulation requirements was observed.

Resident & Staff Files: Resident and staff files stored in the main office.
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File Review: 3 of 3 resident files were reviewed during the visit, and three staff files were reviewed.

Medications/First-Aid Kit: Resident medications are stored in a medication cabinet in the main hallway.

Medication Review: 3 of 3 resident medications were reviewed during the visit.

Continued on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: Jerome Haley
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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 II	FACILITY NUMBER: 306005971
	VISIT DATE: 06/09/2026

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Linens & Hygiene Supplies: Hygiene items were observed in a locked cabinet in the bathroom area.

Garage Area: The garage is clean and well organized. The walkways were free of obstruction. Cleaning supplies are stored in cabinets. Incontinent care supplies were observed, and there’s an extra refrigerator with a supply of nonperishable items.

Backyard/Exterior: The backyard is clean and very well organized. Walkways are free of obstruction. A table and chairs were observed under a shaded patio area.

Bodies of Water: None

Smoke/Carbon Monoxide Detectors: Smoke and carbon monoxide detectors tested operational.

Fire Extinguisher: Fire extinguisher was observed mounted on a wall in the kitchen.

An emergency evacuation drill: Was conducted June 5, 2025. Evacuation drills are conducted monthly.

Emergency Phone Numbers, House Rules, Exit Plan & Menu:

Several facility postings are posted are available for review on the main postings board in the main hallway.

Additional Comments: Licensing fees are current. Resident P&I funds were counted. Emergency food and water was observed in a cabinet in the kitchen. Facility contact information was reviewed during the visit, and the facility number will be updated.

No deficiencies are being cited during today’s visit.

An exit interview conducted, and a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: Jerome Haley
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2026

LIC809 (FAS) - (06/04)

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