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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801811
Report Date: 06/18/2024
Date Signed: 06/18/2024 01:46:44 PM


Document Has Been Signed on 06/18/2024 01:46 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:CYPRESS GARDEN HOME CAREFACILITY NUMBER:
405801811
ADMINISTRATOR:GABRIELA SOOFACILITY TYPE:
740
ADDRESS:824 JACANA COURTTELEPHONE:
(805) 904-6282
CITY:ARROYO GRANDESTATE: CAZIP CODE:
93420
CAPACITY:6CENSUS: 6DATE:
06/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Gabriella SooTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Rankin arrived at 8:30 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 Emergency Disaster Plan. 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.

Physical Plant & Environment Safety: The facility is a 5 bedroom and 3 bathroom home currently occupying 6 residents and 4 staff, including the administrator. 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 gate (on the street view right side of the facility) is being updated for ease of latching and self-closure. The facility has table and chairs available outside with shaded area for resident use. Laundry room has working washer and dryer.

Operational Requirements: The Facility is operating in compliance with fire clearance. The facility provided current up to date liability insurance. All Dementia requirements are being met. Hospice wavier granted for 2, a request to update hospice waiver to 4 is being submitted.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa RankinTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024
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 7


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: CYPRESS GARDEN HOME CARE
FACILITY NUMBER: 405801811
VISIT DATE: 06/18/2024
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Staffing: The facility employes 2 staff and 2 Administrators. Staff records are kept confidential. Staff records were reviewed for 2 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.

Personnel Records & Training: The facility keeps confidential files for each staff member. Training records were current for required 2024 annual training requirements and additional training is scheduled.

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. Files are in compliance.

Resident Rights Information: All require postings were posted in common areas of facility. Personal rights, Rights to Resident Council, Theft and Loss policy, Nondiscrimination notice in addition to a CCL Complaint poster, and LTCO poster.

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.

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.


SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa RankinTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: CYPRESS GARDEN HOME CARE
FACILITY NUMBER: 405801811
VISIT DATE: 06/18/2024
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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 two residents medication, all medications were in original containers, prescription labels were not altered, doctors orders were present and dispensing instructions were followed. Three residents had hospice care plans.

Disaster Preparedness: The current emergency disaster forms were posted. The facility provide disaster drills for 2024, and will add additional drills to their schedules. 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 have one current residents with oxygen. The facility does have hospice and home health visits to the facility for residents in care.


Exit interview conducted, copy of report printed for Administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa RankinTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 06/18/2024 01:46 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: CYPRESS GARDEN HOME CARE
FACILITY NUMBER: 405801811

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(a)(2)
Hospice Care for Terminally Ill Residents
(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (2) The licensee remains in substantial compliance with the requirements of this section, with the provisions of the Residential Care Facilities for the Elderly Act (Health and Safety Code Section 1569 et seq.), all other requirements of Chapter 8 of Title 22 of the California Code of Regulations governing Residential Care Facilities for the Elderly, and with all terms and conditions of the waiver.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interviews, the licensee did not comply with the section cited above in which there are 3 hospice residents when the current wavier is for 2 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2024
Plan of Correction
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Administrator to submit Hospice waiver to increase wavier from 2 to 4.

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 BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa RankinTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 7