<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600378
Report Date: 07/28/2023
Date Signed: 07/28/2023 03:28:04 PM


Document Has Been Signed on 07/28/2023 03:28 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 AC/SC, 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: 150DATE:
07/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Collette Escalante, Business Office ManagerTIME COMPLETED:
03:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Jacqueline Shaw Ross conducted an unannounced annual visit. LPA met with the Business Office Manager, Collette Escalante at the front entrance and was granted entry. The purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with California Code of Regulations, Title 22, Division 6. Facility is approved to serve 293 elderly residents ages 60 and above, in which 290 may be non-ambulatory and 3 bedridden.The facility may also provide hospice care for 10 out of the 290 residents and obtain medication prescribed by a non-physician. The facility is a four-story structure with 149 units.

Tour included:

Physical Plant: The tour of the front entrance, interior and exterior surroundings was observed to be in good repair with no pathway obstruction and facility's hot water temperature measured at 117.6 degrees. Indoor temperature measured 73 degrees. LPA inspected a random sample of residents' apartment units and observed them to be clean, and odor free. The inspection also revealed sufficient lighting and mattress pads in residents’ bedrooms. Furthermore, random smoke and carbon monoxide detectors were also inspected and found to be in working order. All cleaning solutions were observed in a locked secure area. Residents' call system is in working order. LPA Shaw Ross inspected the outdoor waterfall in the courtyard and it meets Title 22 Regulations. Facility does not house firearms and/or ammunition on grounds.

Food Services: 7 day non-perishable and 2 day of perishable food supply was observed, and all food was properly stored and available to residents.

Items reviewed/discussed: Staff present have a criminal record clearance in file and are associated to the facility. LPA Shaw Ross conducted five interviews with residents and five interviews with staff. Facility, staff and residents' records were reviewed and no discrepancies were observed. All required postings were posted in the residents' mail room area as well as throughout the facility. Last emergency drill was conducted on 07/24/2023. Fire extinguishers were inspected and found fully operational.

SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw RossTELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CYPRESS COURT ESCONDIDO
FACILITY NUMBER: 374600378
VISIT DATE: 07/28/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Residents' medications were inspected and are dispensed according to physician's orders.

There were no deficiencies observed per Title 22, Div. 6, Chap 8. An exit interview was conducted and a copy of this report along with a LIC811 was provided to Business Office Manager, Collette Escalante.

SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw RossTELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2