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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601119
Report Date: 12/29/2022
Date Signed: 12/29/2022 10:47:55 AM


Document Has Been Signed on 12/29/2022 10:47 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:CYPRESS HOMEFACILITY NUMBER:
415601119
ADMINISTRATOR:ALEJANDRO, VICTORIAFACILITY TYPE:
740
ADDRESS:537 CYPRESS ST.TELEPHONE:
(510) 326-6759
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY:4CENSUS: 0DATE:
12/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Victoria AlejandroTIME COMPLETED:
11:00 AM
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On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual required 1 year inspection focused on COVID infection control. LPA met with licensee Victoria Alejandro

Upon entry LPA was COVID screened and had temperature taken. Upon entry, LPA did observe COVID postings on the front table and the front door of the facility. LPA toured facility's building and grounds. LPA observed COVID postings through out the facility. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. Resident and staff daily temperature log is observed as current. PPE supply is observed as in place. Medications, toxins and sharps are stored appropriately and inaccessible to clients. Fire extinguishers are observed through out the facility and are tagged as being inspected on 11/22/22. Facility has fire sprinklers in place through out the facility. LPA observed two fire extinguishers and all are charged and dials read as within specifications. Facility lighting is sufficient for residents and staff safety. Water temperature is tested at 118F in full bathroom. Resident shower room is equipped with non-skid mats. Liquid soap is available and paper towels are available in both resident bathrooms. Resident rooms are observed and they are equipped with the required furniture and light fixtures. First-aid kit is inspected as complete. A Disaster and Mass Casualty Plan is posted. Staff are observed wearing masks. Criminal record clearances or exemptions for facility staff or other individuals who have client contact is reviewed. Administrator certificate is observed as current. Resident monies are audited and current per log and cash counting. Surety bond is in place. All staff and residents are fully vaccinated and all boosters.

Continued on attached LIC809-C
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2022
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: CYPRESS HOME
FACILITY NUMBER: 415601119
VISIT DATE: 12/29/2022
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Page 2 - Required 1 Year Annual


The following updated forms are requested to be submitted to CCLD by 01/05/2023:

• LIC 308 Designation of Facility Responsibility
• LIC 400 Affidavit Regarding Client/Resident Cash Resources
• LIC 500 Personnel Report
• LIC 610E Emergency Disaster Plan
• Copy of updated Surety Bond
• Copy of administrator certificate

No citations issued. Report is reviewed with licensee Victoria Alejandro.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
LIC809 (FAS) - (06/04)
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