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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006512
Report Date: 07/02/2024
Date Signed: 08/01/2024 11:22:08 AM


Document Has Been Signed on 08/01/2024 11:22 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
CENTRALIZED APP UNIT, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:CYPRESS BOARD AND CAREFACILITY NUMBER:
306006512
ADMINISTRATOR:BUMANGLAG, ARVINFACILITY TYPE:
740
ADDRESS:5501 CATHY CIRCLETELEPHONE:
(714) 350-1052
CITY:CYPRESSSTATE: CAZIP CODE:
90630
CAPACITY:6CENSUS: 0DATE:
07/02/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Linh Nguyen and Arvin BumanglagTIME COMPLETED:
10:18 AM
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COMP II by CAB successfully completed

Facility Type: RCFE
Application Type: INTL
Capacity: 6
Census : 0
Method: Telephone call with CAB
COMP II Participants: Linh Nguyen & Arvin Bumanglag (Licensees/Administrator) & Tammy Edwards, (Analyst).

Licensees/administrator participated in COMP II via Telephone call with CAB Analyst. Identification of licensees/administrator was verified by confirming driver’s license numbers. During COMP II, licensees/administrator confirmed the understanding of Title 22. Component II was successfully completed. Licensees/administrator were advised to email signed LIC 809 with copy of photo ID to CAB.

During COMP II, CAB analyst confirmed licensees/administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISOR'S NAME: Darla NeeleyTELEPHONE: (916) -65-7817
LICENSING EVALUATOR NAME: Tammy EdwardsTELEPHONE: 916-651-9141
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024
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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