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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005324
Report Date: 01/24/2024
Date Signed: 01/24/2024 04:26:58 PM


Document Has Been Signed on 01/24/2024 04:26 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 16DATE:
01/24/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Melina Nunez, AdministratorTIME COMPLETED:
04:45 PM
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On 01/24/2024, Licensing Program Analyst (LPA) Renee Campbell made an unannounced visit to the facility at approximately 1330. LPA Campbell met with Administrator Melina Nunez and Healthcare Administrator (HA) Cristin Whittaker and stated the purpose of the visit.

LPA Campbell and the Administrator reviewed the facility closure plan to confirm it aligns with Health and Safety Code 1569.682. HA Whittaker confirmed residents and responsible parties were notified of how to contact their ombudsman if they have questions. Whittaker also stated residents were provided information about the rights of residents or their legal representative to investigate the reasons given for eviction as stated in H&S 1569.35. HA Whittaker stated documentation confirming this fact would be proved by 01/26/24.

Per California Code of Regulations, Title 22, there were no deficiencies observed or cited during todays inspection.



Exit Interview
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024
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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