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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600378
Report Date: 10/11/2022
Date Signed: 10/11/2022 05:31:17 PM


Document Has Been Signed on 10/11/2022 05:31 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:ROB JOHNSTONFACILITY TYPE:
740
ADDRESS:1255 N. BROADWAYTELEPHONE:
(760) 747-1940
CITY:ESCONDIDOSTATE: CAZIP CODE:
92026
CAPACITY:293CENSUS: 168DATE:
10/11/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Rob Johnston, Executive Director
Deanna Lyons, Resident Services Director		TIME COMPLETED:
05:40 PM
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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to conduct a case management visit in response to an incident reported on October 10, 2022.

On October 10, 2022, the facility reported a potential inappropriate relationship between Staff #1(S1) and Resident #1(R1). During today's visit, LPA interviewed one (1) staff and one (1) resident. LPA also requested pertinent documents.

No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names List.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2022
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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