405801811-6-23-2021-29-AS-RDLN-C49ST5-20210623140855

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405801811
Report Date: 06/23/2021
Date Signed: 06/23/2021 02:09:41 PM

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 GARDEN HOME CARE		FACILITY NUMBER:	405801811
ADMINISTRATOR:	GABRIELA SOO		FACILITY TYPE:	740
ADDRESS:	824 JACANA COURT		TELEPHONE:	(805) 904-6282
CITY:	ARROYO GRANDE	STATE: CA	ZIP CODE:	93420
CAPACITY:	6	CENSUS: 5	DATE:	06/23/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Gabriela Soo, Administrator		TIME COMPLETED:	12:49 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's (LPA) De Leon conducted an on site 1 year infection control annual visit to the facility above on 06/23/2021 at 10:00 AM. LPA met with Gabriela Soo, Administrator and explained the purpose of the visit. Administrator took LPA on a physical plant tour of the facility. The facility has submitted a mitigation plan to the department. The facility has an entry point at the front door where everyone entering completes sign-in, symptom questionnaire and temperature screening all staff, residents returning from an outing, and visitors coming to the facility. All documentation is kept in binders daily. The entry station has hand sanitizer along with a thermometer. The facility has a large living room area that is used for activities and exercise, all areas are spaced to accommodate as much space as possible for social distancing. All equipment and PPE supplies are kept in a cabinet accessible to all staff. Medications are kept in a magnetic locked drawer in the kitchen and a key locked cabinet in the office. The kitchen area has a dining area to accommodate distancing between residents when eating meals . The staff screen residents for symptoms and temperature 2 x's a day and documentation is kept in residents files. Increased monitoring is conducted if any change of condition is noted or any residents is showing any signs, symptoms or has a temperature. Signs are posted on the entry walls and bathroom doors at the facility regarding Covid-19 symptoms to report to staff, coughing and sneezing etiquette, hand hygiene, mask wearing and social distancing, and PPE donning and doffing. All required postings are hung in common areas of the facility. All 5 residents currently in the facility were not wearing masks. Residents are provided masks when in common areas, visiting, or when going on outings. Staff do give reminders. All staff wear face coverings in the facility. Continued 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

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 3

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 GARDEN HOME CARE	FACILITY NUMBER: 405801811
	VISIT DATE: 06/23/2021

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

Facility has several areas for visiting inside and outside. The facility also offers virtual and telephone communications to all residents in care. The Facility has hand sanitizer located thorough out the facility. Staff, Residents and visitors are informed of the facilities infection control policies. New residents and staff will be tested and negative results received before working or residing in the facility. All residents at the facility are currently all vaccinated. The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed. Emergency Disaster plan is posted and all agencies with telephone numbers are listed. Administrator is in charge of infection control and provides training and education to staff, residents and visitors. Administrator is in charge of staffing and works on any issues or additional coverages needed. If any suspected or confirmed cases of Covid-19 are found in the facility staff will be assigned to only work with those quarantined/isolated individuals and will not work with other individuals until cleared by Health Department to do so. Staff will use full PPE with N95 masks and face shields when dealing with any pending or confirmed cases of Covid-19. Facility is able to dedicate a single room for resident so isolation can be arranged when and if needed. The facility has 3 restrooms for resident use and they are disinfected after use. Signs will be posted on any room with quarantine or isolated individual. PPE supplies will be located right outside those rooms when required. PPE supplies are kept in the laundry room and garage which are accessible to all staff. Facility has a 30 day supply of PPE on hand. Trash bins used for infection control have tight fitting lids. Facility has plans for delivering medications and meals to any quarantined/isolation room. The facility has proper cleaning and disinfectant sprays. The facility has not been fitted tested for N95 masks and LPA explained in an outbreak the facility would need to be wearing N95 and to check with CAL OSHA for required fit testing of those masks. LPA's highly recommended Licensee look into testing for the N95 masks before an outbreak. Facility Administrator has a plan in place for when and whom to notify in an outbreak or for other emergencies. Administrator will keep a line list of all vaccinated and tested staff or residents in care with dates/results. Facility has conducted training on infection prevention, symptoms, transmission and PPE use. Facility has non-punitive sick leave polices for staff. Sick staff are requested to stay home and not report to work if ill. Activities have been modified to individuals or small groups with social distancing. Some of the furniture has been moved around to accommodate social distancing between staff and residents. Continued 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

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 GARDEN HOME CARE	FACILITY NUMBER: 405801811
	VISIT DATE: 06/23/2021

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 medication is delivered in 30 day supplies to the facility in bubble packs. The facility ensures proper cleaning is done on frequently touched surfaces and between any individuals sharing of space or items. Sinks were well stocked with soap and paper towels. Staff and resident records are kept locked in cabinets. Facility does realize guidance changes and the most up to date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance and LPA reminded Administrator the most stringent orders/guidelines released should be followed.

Water was tested in the resident master bathroom at 120.0 F and in the front resident bathroom at 111.2 degrees F. The facility had perishable food for 2 days and non-perishables for 7 days for 5 residents in care.

The inside and outside of the facility are clean ,safe and sanitary for all residents, staff and visitor use. Facility has smoke/carbon monoxide detectors and fire extinguisher.

No deficiencies observed during the visit and all infection control protocols are implemented and followed by the facility.

Exit interview completed and copy of report given to Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3