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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006512
Report Date: 07/30/2024
Date Signed: 07/30/2024 11:04:17 AM


Document Has Been Signed on 07/30/2024 11:04 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



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:
07/30/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Arvin Bumanglang
Linh Nguyen
TIME COMPLETED:
11:15 AM
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Licensing Program Analysts (LPA) Jerome Haley conducted an announced visit to the facility to conduct the pre-licensing inspection. LPA Haley met with Applicants Arvin Bumanglang, Linh Nguyen and toured the facility.
An initial application to operate a Residential Care Facility Elderly (RCFE) was submitted to CCL on February 9, 2024. The facility has a capacity of 6, of which 2 can be non-ambulatory, and one may be bedridden. The facility phone number 714.723.0008.

Fire clearance: Orange County Fire Authority granted the fire clearance March 26, 2024.

Structure: The facility is one level structure with 4 bedrooms and 2 bathrooms.

Kitchen: Clean and organized. Sharps locked in a cabinet near the sink. Cleaning chemicals are kept locked under the sink. Staff and resident files are kept in a locked cabinet with a first aid kit with all the required elements.

Food Service/Menu: A sample menu as posted on the refrigerator. A supply of perishable items, a supply of nonperishable items, and fruits were observed.

Stove/Appliances:
Gas stove with 5 burners was clean and lighted unassisted. All other appliances were clean and in good working condition.

Toxins:
All cleaning supplies and chemicals are kept in the kitchen in a locked cabinet below the sink, and an additional supply of cleaning chemicals will be kept locked in a cabinet in the garage.

pg 1 of 3 Continued on LIC809C
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024
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 3


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: CYPRESS BOARD AND CARE
FACILITY NUMBER: 306006512
VISIT DATE: 07/30/2024
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Medications, First-Aid Kit:
Resident medications will be locked in a cabinet in the kitchen. A first aid kit is locked in a cabinet in the kitchen where the staff and resident files are kept.

Resident/Client & Staff Files:
The resident and staff records will be kept locked in the cabinet in the kitchen.

Bedrooms: All resident bedrooms had all the required elements (bed, lamb, chair, & storage space) and were in compliance with regulation guidelines.

Bathrooms:
The resident bathroom has a working toilet, wash basin and shower. Grab bars were tightly secured to the wall. Both bathrooms were clean and organized. There's 1 bathrooms in the facility for residents and a half bathroom in the staff bedroom for staff.

Hot Water:
Hot water was measured at 117.8 degrees F and 119.8 degrees F.

Hygiene Supplies:
Additional hygiene items will be stored in the garage in one of the locked storage cabinets.

Linens, Hygiene, Emergency Supplies:
An emergency food bucket was observed in the garage.

Garage: The garage is used as a storage space to store extra items like: adult diapers, hand sanitizers, N95 mask, toilet paper, holiday decorations, and other facility items. There’s a laundry area in the garage with a washer and dryer. There's a few locked storage cabinets in the garage that will be used to store additional items like an additional supply of non-perishable food items, an extra supply of linens, and additional cleaning supplies and cleaning chemicals.

pg. 2 of 3 Continued on LIC809C
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: CYPRESS BOARD AND CARE
FACILITY NUMBER: 306006512
VISIT DATE: 07/30/2024
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Backyard: Clean and organized. Table with a sunshade and chairs. There’s a locked shed used to store tools, paint, and a lawn mower.

Smoke Detectors/Carbon Monoxide Detectors: Smoke detectors/carbon monoxide detectors are hardwired and tested operational. There is fire extinguisher mounted in the kitchen.

Component III: Component III was waived. Applicants already operate other licensed facilities.

Recommendation/Corrections: Applicants were advised to monitor the hot water temperature. There are no additional corrections to be made. The facility will be recommended for licensure.

Exit Interview: Exit interview was conducted, and a copy of this report was provided.

pg 3 of 3
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3