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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600378
Report Date: 07/28/2022
Date Signed: 07/28/2022 02:05:24 PM


Document Has Been Signed on 07/28/2022 02:05 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



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: 167DATE:
07/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Rob Johnston, Administrator
Deeanna Lyons, Resident Care Director		TIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conduct an annual inspection with emphasis on infection control. LPA was screened for COVID symptoms and elevated temperature upon arrival. LPA met with Administrator Rob Johnston and Resident Care Director Deeanna Lyons and explained the purpose of the visit.
During today's visit, LPA toured and inspected the facility for regulatory compliance for the mitigation of COVID-19. LPA observed appropriate postings in the facility which were in accordance with the Department's guidelines. LPA observed that the facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). The facility has an approved COVID-19 Mitigation Plan Report (Report) on file which identifies a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases and ensures that staff are trained in the facility's infection control measures. The Report also indicates the facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolation, and properly caring for residents with COVID-19 positive results and/or exposures. Also detailed in the Report is a plan to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the resident presents any COVID-19 symptoms.

No deficiencies were observed during today's visit. An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022
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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