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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600378
Report Date: 06/15/2021
Date Signed: 06/15/2021 01:58:07 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: 122DATE:
06/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Rob Johnston, AdministratorTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Adam Hamer conducted an unannounced annual required licensing inspection on today's date. LPA was greeted at the front entrance by Azalea Ayala, receptionist; Administrator Rob Johnston and Resident Care Director Lisa Chavarria were also present and came to the reception area to greet LPA, who was granted entry after identifying himself and disclosing the purpose of the visit. An overall tour of the facility was conducted inside and out. The inspection included, but was not limited to, verifying compliance with statutes, regulations and other written requirements that are most relevant to protecting the health of residents in care and staff, including in the area of infection control practices.

LPA reviewed the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report (LIC 808) with Mr. Johnston and Ms. Chavarria, including the following sections: Person in Care, Staff, Visitors, Facilities without COVID-19, Residents, Facility has Plans for Infection Control, and Physical Distancing. LPA assessed the strategies that the facility is employing for the prevention, containment and mitigation of COVID-19, implementation of infection control guidance, staff retention and essential health and safety.

LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, residents and visitors; a sign-in policy enacted for all visitors; signs posted at facility entrance with the facility’s visitor policy and signs throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; face coverings worn by staff and residents as much as possible; hand sanitizer/hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of PPE. The facility is in compliance with and has implemented infection control practices as outlined in its LIC 808.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Adam HamerTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021
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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: CYPRESS COURT ESCONDIDO
FACILITY NUMBER: 374600378
VISIT DATE: 06/15/2021
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No deficiencies were observed during today's visit. An exit interview was conducted with Mr. Johnston and Ms. Chavarria and a copy of this report along with the Licensee Rights (LIC 9058 FAS 01/16) were provided to Mr. Johnstion via email, and he expressed to LPA that he will send a confirmation upon receipt of said documents.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Adam HamerTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021
LIC809 (FAS) - (06/04)
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