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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881316
Report Date: 07/27/2022
Date Signed: 07/27/2022 01:38:29 PM

Document Has Been Signed on 07/27/2022 01:38 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:DESERT CYPRESS ELDERCAREFACILITY NUMBER:
331881316
ADMINISTRATOR:CAYABYAB, ARCITA AFACILITY TYPE:
740
ADDRESS:68905 HERMOSILLO ROADTELEPHONE:
(760) 459-3214
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY: 6CENSUS: 0DATE:
07/27/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:26 PM
MET WITH:Arcita Cayabyab, AdministratorTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Jesse Gardner conducted an announced pre-licensing inspection to the facility to complete the pre-licensing inspection and Comp III. Upon arrival, LPA met with Administrator Arcita Cayabyab. Administrator Arcita Cayabyab accompanied LPA on a tour of the inside and outside of the facility.

Currently there are no residents in care. The facility is a 5 bedroom, 4 bathroom home with a living room and kitchen. Per the approved fire clearance, the licensee is approved for 6 non-ambulatory residents. All bedrooms are furnished with bed, night stand, dressers and have adequate lighting for residents use.

The facility currently has linens, towels and a sufficient amount of hygiene products for residents. The water temperature was tested and is within the 106.0-117.6 degrees. The smoke alarms and carbon monoxide alarm were tested and are in operating order. LPA observed a fully charged fire extinguisher which was present in the kitchen/dining room area. The kitchen was observed to have dishes, silverware and pots and pans. The medications, will be stored in a locked cabinet in the hallway, with the knives locked in the kitchen. The chemicals will be stored in a locked cabinet in the garage.

The backyard was observed to be fully fenced with an unlocked gate and shade will be provided by an awning from the house.

LPA found all facility features to be in compliance and in line with Title 22 Regulations.

An exit interview was conducted and a copy of this report was reviewed with and provided to Administrator Arcita Cayabyab.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2022
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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