405801811-5-21-2025-29-AS-RDLN-DGVRZP-20250521132817

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405801811
Report Date: 05/21/2025
Date Signed: 05/21/2025 01:28:33 PM

Document Has Been Signed on 05/21/2025 01:28 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	CYPRESS GARDEN HOME CARE		FACILITY NUMBER:	405801811
ADMINISTRATOR/ DIRECTOR:	GABRIELA SOO		FACILITY TYPE:	740
ADDRESS:	824 JACANA COURT		TELEPHONE:	(805) 904-6282
CITY:	ARROYO GRANDE	STATE: CA	ZIP CODE:	93420
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	05/21/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:10 AM
MET WITH:	Gabriela Soo, Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:35 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) Rankin arrived at 9:10 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 Infection Control Plan. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. The facility is provided annual training for infection control with all staff. Physical Plant & Environment Safety: The facility is a 5 bedroom and 3 bathroom home currently occupying 6 residents and 3 staff and 2 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. The gates are self-latching and self-closing. 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. The facility is granted for 6 non-ambulatory with 1 can be bedridden and Hospice wavier granted for 4. Continued 809-C

Kelly Burley	TELEPHONE: (805) 562-0413
Rachael De Leon	TELEPHONE: (805) 450-0262
	DATE: 05/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 05/21/2025

NARRATIVE

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Staffing: The facility employes 4 staff and 2 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 was reviewed for continuing education and Administrator Certificate is valid till 04/18/2026.
Personnel Records & Training: The facility keeps confidential binder with taps for each staff member. Training records were present for 2024-2025 for 20 plus hours of 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. Files are current meeting all required forms on file.
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.
Incidental Medical & Dental: Facility provides transportation or assist in providing 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) all were up to date, legible and written as prescribed. LPA completed a full audit of residents medication, all medications were in original containers, prescription labels were not altered, No medications were expired, doctors orders were present and dispensing instructions were followed.

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: 05/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025

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: 05/21/2025

NARRATIVE

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Disaster Preparedness: The current emergency disaster forms were posted. The facility provide disaster drills for 2025. 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.
the facility had emergency food and water present.

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 1 hospice residents in care, care plan is up to date and present. The facility does have one Home Health resident in care, home health plan is present and kept up to date. The facility does not have delayed egress. The facility does not have any current residents on oxygen. The facility has exiting door alarms, tested and working properly.

Exit interview conducted, copy of report 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: 05/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025

LIC809 (FAS) - (06/04)

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