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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005324
Report Date: 07/08/2022
Date Signed: 07/08/2022 01:27:40 PM


Document Has Been Signed on 07/08/2022 01:27 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:CYPRESS ASSISTED LIVINGFACILITY NUMBER:
507005324
ADMINISTRATOR:MELINA NUNEZFACILITY TYPE:
740
ADDRESS:1801 NORTH OLIVE AVENUETELEPHONE:
(209) 410-7243
CITY:TURLOCKSTATE: CAZIP CODE:
95382
CAPACITY:49CENSUS: 9DATE:
07/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Associate Executive Director Jianne BassiTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Jason Lund arrived at the above address to conduct an unannounced annual/required inspection. LPA met with Associate Executive Director Jianne Bassi and explained the purpose of the visit.

LPA Lund and Associate Executive Director Jianne Bassi walked the facility the physical plant including but not limited to kitchen, bedrooms, bathrooms, living and dining room area. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present in/or around the facility. LPA observed sufficient seven- day non-perishable and two- day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. Carbon dioxide monitor present and operational. LPA observed centrally stored medications locked inside the medication room.

No deficiencies were observed during this annual/required inspection. Exit interview held with Associate Executive Director Jianne Bassi and a report left.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2022
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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