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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801659
Report Date: 07/09/2024
Date Signed: 07/10/2024 10:06:59 AM


Document Has Been Signed on 07/10/2024 10:06 AM - 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:CYPRESS RIDGE HOME CAREFACILITY NUMBER:
405801659
ADMINISTRATOR:ROXANDRA WHITESTINEFACILITY TYPE:
740
ADDRESS:2312 SANDERLING COURTTELEPHONE:
(805) 202-8990
CITY:ARROYO GRANDESTATE: CAZIP CODE:
93420
CAPACITY:6CENSUS: 5DATE:
07/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Rachelle Tellez, Back up AdministratorTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) De Leon arrived at 9:30 am to conducted a 1 year annual visit to the facility above. LPA met with Back up Administrators Jessica Bailey and Rachelle Tellez and explained the purpose of the visit.

A tour of the inside and outside of the facility was conducted with Administrators. The following was inspected and noted during the annual visit:

Infection Control: The facility has submitted a current Mitigation Plan, Infection Control Plan and Emergency Disaster Plan. The facility has EPA approved disinfectants spray and cleaners. The facility has trash bins with lids/covers. The facility has a 30 day supply of PPE. The facility staff have taken annual Infection control and PPE training.
Physical Plant & Environment Safety: The facility is a 6 bedroom and 6 bathroom home currently occupying 5 residents and 7 staff, including 3 administrators. The facility is clean, safe and sanitary. The pathways are clear of any obstructions. The facility has sufficient space inside and outside for activities and visiting. Laundry room has working washer and dryer.
Operational Requirements: The Facility is operating in compliance with fire clearance. Capacity is 6 with 1 non-ambulatory and 5 bedridden with a hospice waiver for 3. The facility has current liability insurance on file. The facility has dual hard wired smoke and carbon monoxide detectors.
Staffing: The facility employes 7 staff and 3 Administrators. Staff records are kept confidential. Staff records were reviewed for 5 staff. Staff records had fingerprint clearance and associations with criminal record statements, personnel record or application, First Aid and CPR certificates and Health screening with TB results. Administrator file has all CEU/education requirements to renew Administrator Certificate, Administrators are on the active or pending list.

Continued 9099-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024
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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: CYPRESS RIDGE HOME CARE
FACILITY NUMBER: 405801659
VISIT DATE: 07/09/2024
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Personnel Records & Training: The facility keeps confidential files for each staff member. Training records were current for required 2024 annual training.
Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Five Files were reviewed for signed Admission Agreements, Medical Assessments, LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. All files reviewed were meeting compliance requirements.
Resident Rights Information: All require postings were posted in common areas of facility. Personal rights, Rights to Resident Council, Theft and Loss policy, Non-discrimination notice in addition to a CCL Complaint poster, PIN, License, Hospice Waiver, Emergency Disaster plan and LTCO poster.
Planned Activities: The facility offers activities to all residents in care. Activities include arts and crafts, books, magazines, newspapers, TV watching, daily walks, group discussions and communications, and puzzles. The facility has sufficient space to allow for activities indoors and outdoors.
Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available in the pantry and garage.
Incidental Medical & Dental: Facility provides transportation to medical and dental appointments when needed. The medications records were reviewed for all 5 residents with the Centrally Stored Medication and Destruct Records (CSMDR). LPA inspected 5 residents medications, all medications were in the original containers, prescription labels were not altered, and no medications were expired. Doctors orders were present and dispensing instructions were followed.
Disaster Preparedness: The current emergency disaster forms were posted. The facility provided quarterly disaster drills for 2023-2024. The fire extinguishers were charged and tags are dated within the last year.
Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked separately in cupboards. The facility does have hospice and home health visits to the facility for residents in care. Facility is completely fenced with self closing and self latching gates. The facility does not have delayed egress. The facility does not have any residents currently using oxygen.

Exit interview conducted, copy of report printed for Administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024
LIC809 (FAS) - (06/04)
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