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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600378
Report Date: 11/25/2024
Date Signed: 11/25/2024 01:26:17 PM

Document Has Been Signed on 11/25/2024 01:26 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CYPRESS COURT ESCONDIDOFACILITY NUMBER:
374600378
ADMINISTRATOR/
DIRECTOR:		ROB JOHNSTONFACILITY TYPE:
740
ADDRESS:1255 N. BROADWAYTELEPHONE:
(760) 747-1940
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY: 293CENSUS: 159DATE:
11/25/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Administrator, Tania DupreTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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On 11/25/2024, Licensing Program Analyst (LPA), Janette Romero conducted an unannounced case management visit to address a deficiency observed during a complaint investigation. LPA met with Administrator, Tania Dupre and Business Office Manager, Collette Escalante who were informed of the purpose of the visit. During a record review, LPA observed the facility has not paid their annual licensing fees due on 7/12/2024 and has a current balance of $4,455.00. The facility will be cited. An exit interview was conducted and a copy of this report was reviewed and provided to Administrator Dupre along with an LIC 809-D and Appeal Rights.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2024
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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Document Has Been Signed on 11/25/2024 01:26 PM - It Cannot Be Edited


Created By: Janette Romero On 11/25/2024 at 01:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CYPRESS COURT ESCONDIDO
FACILITY NUMBER: 374600378

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/09/2024
Section Cited
CCR
87156(a)

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87156 Licensing Fees
(a) An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185.
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Licensee reported they will pay their licensing fees and provide proof of correction to LPA by close of business on POC due date.
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During a record review, LPA observed the facility has not paid their annual licensing fees due on 7/12/2024 and has a current balance of $4,455.00. This poses a potential health or safety risk to clients in care.
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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:Tricia Danielson
LICENSING EVALUATOR NAME:Janette Romero
LICENSING EVALUATOR SIGNATURE:
DATE: 11/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/25/2024


LIC809 (FAS) - (06/04)
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