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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005324
Report Date: 03/20/2024
Date Signed: 03/20/2024 11:58:16 AM


Document Has Been Signed on 03/20/2024 11:58 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
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: 0DATE:
03/20/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Melina Nunez, AdministratorTIME COMPLETED:
12:15 PM
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On 03/20/24 at 10 am, Licensing Program Analyst (LPA) Renee Campbell conducted an announced case management inspection to ensure there are no residents in place and to close the license per the LIcensee's request. LPA met with Melina Nunez, Administrator and together conducted a tour of the home to ensure no residents are currently in place.

LPA Campbell toured the facility with the administrator and confirmed there are no residents currently in placement at the facility. The Administrator confirmed they are voluntarily relinquishing their license and understand that to obtain a license again it would require a new application. LPA Cambpell obtained the copy of the facility license from the administrator..

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

LPA thanked the administrator for being a part of our program and for the service provided to our community.

This license will be referred to support staff for closure.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024
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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