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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600378
Report Date: 12/02/2020
Date Signed: 12/02/2020 03:23:31 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:CYPRESS COURT ESCONDIDOFACILITY NUMBER:
374600378
ADMINISTRATOR:DANIEL-HERR, DONNAFACILITY TYPE:
740
ADDRESS:1255 N. BROADWAYTELEPHONE:
(760) 747-1940
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY:293CENSUS: 136DATE:
12/02/2020
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Donna Daniel-Herr, AdministratorTIME COMPLETED:
12:35 PM
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Licensing Program Manager, Denise Powell, County of San Diego Nurse Contractors, Robert Montillano, and Susan Brackman; and California Department Public Health (CDPH), Health Facility Evaluator Nurse (HFEN), Michelle Hose with the HAI Program, conducted an on-site visit. LPM and public health team identified themselves and discussed the purpose of the visit with Administrator, Donna Daniel-Herr and Assisted Living Director Lisa Chavarria.

The Department conducted the on-site visit to provide technical assistance and to evaluate the facility's disinfection, testing surveillance, screening protocols as well as the use of personal protective equipment. During today's visit, the team interviewed Ms. Daniel-Herr and Ms. Chavarria and conducted a walk-though of the facility. A debriefing was conducted with the Administrator at the conclusion of the visit.

During today's visit, no deficiencies were issued. An exit interview was conducted with the Administrator and a copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided to her via electronic mail. An electronic receipt of confirmation was requested to be sent upon receipt of the documents.
SUPERVISOR'S NAME: Icela EstradaTELEPHONE: (619) 688-6866
LICENSING EVALUATOR NAME: Denise PowellTELEPHONE: 619-301-9770
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2020
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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