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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600378
Report Date: 08/05/2022
Date Signed: 08/05/2022 02:51:10 PM


Document Has Been Signed on 08/05/2022 02:51 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:
08/05/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Rob Johnston, Administrator
Deanna Lyons, Resident Care Director		TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Tricia Danielson and Regional Manager (RM) Reyna Lacey arrived unannounced to the facility conduct a case management visit following receipt of a death report of Resident #1(R1).
On August 4, 2022, Community Care Licensing (CCL) received an death report notification concerning R1. During today's visit, LPA and RM obtained copies of pertinent documents and toured the facility.

No deficiencies cited during today's visit. An exit interview was conducted and a copy of this report was provided along with LIC 811- Confidential Names list.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2022
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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