405801811-4-21-2023-29-AS-RDLN-CR5284-20230421170943

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405801811
Report Date: 04/21/2023
Date Signed: 04/21/2023 05:10:51 PM

Document Has Been Signed on 04/21/2023 05:10 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, 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: 4	DATE:	04/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Administrator/Licensee Gabriela Soo		TIME COMPLETED:	05:20 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) De Leon arrived at 11:00 am to conducted a 1 year annual visit to the facility above. LPA met Licensee/Administrator Gabriella Soo and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Infection Control: The facility has submitted a current Mitigation Plan, Infection Control Plan and needs to update the Emergency Disaster Plan and provide to the department. The facility has a sign in and out binder for visitors at entry with hand sanitizer and symptom screening. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectants spray and cleaners. The facility has trash bins with covers. The facility has a 30 day supply of PPE. New residents are tested and negative results received before residing in the facility. Sick staff are requested to stay home and not report to work if ill. Quarantined or isolated individuals will have meals and medication delivered to rooms. Physical Plant & Environment Safety: The facility is a 5 bedroom and 3 bathroom home currently occupying 4 residents and 5 staff. 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. The gates on each side of the facility are in need of repair to be self-closing and self-latching. The facility has table and chairs available outside with shaded area for resident use. Laundry room has working washer and dryer.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

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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Document Has Been Signed on 06/23/2023 04:43 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 04/21/2023 06:24 PM

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.605

Other Provisions

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation & record review, the licensee did not comply with the section cited above the Licensee/Administrator was unable to provide up to date liability insurance which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/28/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator agreed to obtain current liability insurance and provide copy of policy to CCL.

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation & record review, the licensee did not comply with the section cited above 3 staff did not have 2023 annual training which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/28/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator argeed to have all 3 staff take 2023 Annual Traning and provide records to CCL.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

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 GARDEN HOME CARE	FACILITY NUMBER: 405801811
	VISIT DATE: 04/21/2023

NARRATIVE

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Operational Requirements: The Facility is operating in compliance with fire clearance. The facility was not able to provided current up to date liability insurance. All Dementia requirements are being met. Hospice wavier granted for 2.

Staffing: The facility employes 3 staff and 2 Administrators. Staff records are kept confidential. Staff records were reviewed for 3 staff and 2 Administrators. Staff records had finger print clearance and associations with criminal record statements, personnel record or application, First Aid and CPR certificates and Health screening with TB results. Two staff and 1 Administrator did not have current first aid.

Personnel Records & Training: The facility keeps confidential files for each staff member. Training records were not current for required 2023 annual training requirements.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Four Files were reviewed for signed Admission Agreements, Medical Assessments, LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), Immunization records, TB results, Personal Rights, and Safeguard for personal property and valuables. 2 out of 4 residents needed updated ANS and 2 LIC 602A physician report. Facility does submit incident reports to the department when required.

Resident Rights Information: All require postings were not posted in common areas of facility. Personal rights, Rights to Resident Council, Theft and Loss policy, Nondiscrimination notice. CCL Complaint poster, and LTCO poster were posted in the common areas of facility.

Planned Activities: The facility offers activities to all residents in care. Activities include 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.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

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 GARDEN HOME CARE	FACILITY NUMBER: 405801811
	VISIT DATE: 04/21/2023

NARRATIVE

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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 garage.

Incidental Medical & Dental: Facility provides transportation to medical and dental appointments when needed. The medications records were reviewed for all 4 residents with the Centrally Stored Medication and Destruct Records (CSMDR) all were up to date, legible and written as prescribed. LPA completed a full audit on one residents medication, all medications were in original containers, prescription labels were not altered, doctors orders were present and dispensing instructions were followed. Two residents had hospice care plans.

Disaster Preparedness: The current emergency disaster forms were not posted. The facility could not provide quarterly disaster drills for 2023. The fire extinguishers were charged and receipt was dated within 1 year. The dual smoke and carbon monoxide detectors are present and hard wired throughout the facility.

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 has a license for 6 Non Ambulatory which 1 may be bedridden on room 1. The facility does not have delayed egress. The facility does not have any current residents with oxygen. The facility does have hospice and home health visits to the facility for residents in care.

LPA conducted interviews with 1 Resident and 2 Staff.

Exit interview conducted, deficiency cited, technical violations issued, Copy of report and appeal rights printed for Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

LIC809 (FAS) - (06/04)

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