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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005212
Report Date: 10/27/2022
Date Signed: 10/27/2022 01:39:01 PM


Document Has Been Signed on 10/27/2022 01:39 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:CYPRESS HOME CAREFACILITY NUMBER:
347005212
ADMINISTRATOR:BISCOS, DINAFACILITY TYPE:
740
ADDRESS:4801 CYPRESS AVENUETELEPHONE:
(916) 993-8479
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 3DATE:
10/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:TIME COMPLETED:
01:45 PM
NARRATIVE
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On 10/27/2022, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced to conduct a Required 1-yr inspection. LPA spoke with Licensee, Dina Biscos and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA confirmed there are no residents or staff with a confirmed case or signs/symptoms or Covid. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. When LPA arrived at the facility, LPA observed Licensee taking R1 to the car. LPA was informed R1 had a doctor's appointment. LPA then contacted Administrator, Mariana Oltean, who arrived shortly to the facility.

LPA and Licensee then toured the interior of the facility together. Rooms toured include (3) private residents bedrooms, (2) vacant bedrooms, (1) visitor's bedroom, (1) private bathroom, (1) shared bathroom, laundry room, kitchen, garage and common areas. LPA observed a bottle of hydroperoxide to be located on the shelf of R1's private bathroom. Licensee also informed LPA that R1 has dementia. LPA observed a room to be occupied by an individual that Licensee confirmed is not fingerprinted. Licensee informed LPA that S1 has been at the facility for a few days. LPA observed medications for R2 to be pre-poured for greater than 24 hours. LPA observed S2 to be present, going up stairs and downstairs and into the kitchen without a face mask.

LPA observed the facility to have 2+ day of perishables and 7+ days of non-perishables. LPA observed facility to have ample supply of PPE. LPA informed Licensee shared bathrooms needs to have paper towels. LPA informed Licensee fire extinguishers will need to be serviced every year, it was observed to be last serviced 09/13/2021.

Please continue on LIC 809-C...
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022
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 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: CYPRESS HOME CARE
FACILITY NUMBER: 347005212
VISIT DATE: 10/27/2022
NARRATIVE
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Continued from LIC 809...

LPA observe the Administrator Certificate to be pending on CDSS website. LPA and Licensee completed the infection control domain and deficiencies were observed. Please see the attached LIC 9102, LIC 809-Ds and LIC 421BG.

Additionally, LPA requested copies of LIC 500, LIC 308, and current liability insurance to be emailed to LPA by Friday November 4, 2022.

Exit interview conducted and a copy of report and appeal rights was left at the facility.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/27/2022 01:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: CYPRESS HOME CARE
FACILITY NUMBER: 347005212

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(f)(2)
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as a bottle of hydroperoxide was left accessible in R1's bathroom, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/04/2022
Plan of Correction
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Licensee immediately removed the product and placed it in a secured area. Licensee agrees to read Regulation 87705 with staff and submit a signed statement that the regulation is understood. Submit by 11/4/22 via fax or email.
Type B
Section Cited
CCR
87465(h)(5)
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 3 resident's medication was weekly pre-poured and not in original containers, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/04/2022
Plan of Correction
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Licensee will submit their medication procedures to not pre-pour medications for greater that 24 hours to CCL via fax or email by the POC date of 11/04/22.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 10/27/2022 01:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: CYPRESS HOME CARE
FACILITY NUMBER: 347005212

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)
87355 Criminal Record Clearance. (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and interview, Licensee did not comply with the section cited above in as 1 individual is not associated to the facility on Guardian. Licensee stated S2 has been living at the facility for a "few" days and has no where else to go, which poses/posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2022
Plan of Correction
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Licensee agrees to remove the individual from the facility immediately. Licensee is to submit proof of S2's fingerprinting to CCL and their plan of ensuring all individuals living at the facility is to be associated and fingerprint cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4