331881316-8-12-2024-18-AS-SJEN-D83PUT-20240812113804

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881316
Report Date: 08/12/2024
Date Signed: 08/12/2024 11:38:19 AM

Document Has Been Signed on 08/12/2024 11:38 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	DESERT CYPRESS ELDERCARE		FACILITY NUMBER:	331881316
ADMINISTRATOR/ DIRECTOR:	CAYABYAB, ARCITA A		FACILITY TYPE:	740
ADDRESS:	68905 HERMOSILLO ROAD		TELEPHONE:	(760) 459-3214
CITY:	CATHEDRAL CITY	STATE: CA	ZIP CODE:	92234
CAPACITY: 6		CENSUS:	DATE:	08/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:18 AM
MET WITH:	Arcita Cayabyab, administrator		TIME VISIT/ INSPECTION COMPLETED:	11:45 AM

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Licensing Program Analyst (LPA), Seo Jeon, made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was greeted and allowed to enter the facility to conduct the inspection. On today’s visit the LPA met with administrator, Arcita Cayabyab and she was notified of the purpose for the visit.

The facility is a single story home with 5 bedrooms and 4 bathrooms, complete with an attached garage. There are no pools or other bodies of water on the premises, and no known firearms or dangerous weapons are stored at the facility. The clients served are adults 60 and up.

LPA observed the hand washing stations in the facility restrooms and kitchen, which were equipped with hand hygiene supplies and hand washing signs. Additionally, LPA noticed the presence of personal protective equipment (PPE) and cleaning supplies for regular facility maintenance.

LPA observed the client bedrooms and staff office. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for clients. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke and carbon monoxide detectors were operational, and the hot water temperature was 116 degrees F. Fire extinguisher located in living room area had current inspection tag.

LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

Continued on LIC809-C...

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: DESERT CYPRESS ELDERCARE	FACILITY NUMBER: 331881316
	VISIT DATE: 08/12/2024

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Adequate staff were present for the supervision of clients during the visit. LPA also reviewed the staff scheduled showing adequate staff coverage. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator possesses a current administrator's certificate.

LPA reviewed two(2) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Three (3) client files were reviewed and possessed all required paperwork.

All client medication was locked in a cabinet located in the kitchen area. LPA reviewed medications for three (3) clients and found all medication listed on MARs and all required labeling was found to be in place.

LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility performs quarterly fire and earthquake drills, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in the kitchen and first aid kit with all required items.

No deficiencies were cited per Title 22, Division 6 of the California Code of Regulations at this time.

An exit interview was conducted where a copy of this report was provided to administrator, Arcita Cayabyab.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024

LIC809 (FAS) - (06/04)

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