374600378-7-25-2024-18-AS-VMIN-D7HP7T-20240725110427

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374600378
Report Date: 07/25/2024
Date Signed: 07/25/2024 11:04:39 AM

Document Has Been Signed on 07/25/2024 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	CYPRESS COURT ESCONDIDO		FACILITY NUMBER:	374600378
ADMINISTRATOR:	ROB JOHNSTON		FACILITY TYPE:	740
ADDRESS:	1255 N. BROADWAY		TELEPHONE:	(760) 747-1940
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92026
CAPACITY:	293	CENSUS: 161	DATE:	07/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:38 AM
MET WITH:	ADMINISTRATOR, TANIA DUPRE		TIME COMPLETED:	11:18 AM

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On July 25, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the Required Annual Inspection and met with the Administrator, Tania Dupre. The facility file review was conducted at the Regional Office and additional forms were requested and reviewed on site. The facility is licensed for 293 Elderly Adults and is currently operating at a capacity of 161 Older Adults (740).

LPA Mixson toured the facility, and inspected the facility inside and outside. There were no obstructions or debris to the indoor or outdoor passageways at the time of this visit. The facility has several levels for a total of four on one side and three floors on the other side of the building, and is located at 1255 N. Broadway Escondido, CA 92026.

Physical Plant: The facility phone number is (760) 747-1940 and is operable. LPA Mixson observed a sample the residents’ living units, and each was equipped with required furniture as per Title 22. LPA Mixson inspected a sample of the facility restrooms on the first and second floors, and the hot water temperature tested within regulations. The bathrooms were clean, and appliances were operating appropriately, and there was liquid soap and paper towels currently at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. LPA Mixson observed required postings such as "If you See Something, Say Something" the "Personal Rights," along with the Ombudsman. The cleaning supplies and sharp items were kept locked and inaccessible to the residents in care. There was a designated storage space for the residents and staff files, and it was locked and inaccessible to residents in care currently at the time of this visit.

Medications: Were locked and inaccessible to residents in care, and there was a sufficient supply of medication for each resident. There was a Wellness Center and/or Nurses station and it was lockable. The facility cooling system and other appliances were operable currently at the time of this visit. LPA was informed by the Administrator that there were safety lights for night throughout the facility.

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SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus Mixson	TELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CYPRESS COURT ESCONDIDO	FACILITY NUMBER: 374600378
	VISIT DATE: 07/25/2024

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CONTINUED FROM LIC-809

Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Dishes and utensils were in sufficient supply and stored properly, and sharp items are locked.

Care & Supervision: Facility has sufficient staff on site at the time of this visit. Receptionist at the front desk, maintenance team, and house keeping teams were observed on each floor. Nurses and other care staff were in sufficient numbers for this facility type.

Records Review: LPA Mixson reviewed resident and staff files, conducted resident and staff interviews, and reviewed previous Community Care Licensing forms. There were no Title 22, Division 6 Regulation violations observed or cited during today’s visit.

An exit interview was conducted, and a copy of this report was discussed and provided to Administrator, Tania Dupre.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus Mixson	TELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024

LIC809 (FAS) - (06/04)

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