<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547202684
Report Date: 05/06/2022
Date Signed: 05/06/2022 12:22:53 PM

Document Has Been Signed on 05/06/2022 12:22 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:CYPRESS CARE HOME #3FACILITY NUMBER:
547202684
ADMINISTRATOR:REYES, VICTORIA DELOSFACILITY TYPE:
735
ADDRESS:1870 WAGONWHEEL CT.TELEPHONE:
(559) 688-2004
CITY:TULARESTATE: CAZIP CODE:
93274
CAPACITY: 6CENSUS: 4DATE:
05/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:02 PM
MET WITH:Administrator Victoria De Los ReyesTIME COMPLETED:
12:38 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) Lady Cabrera arrived unannounced for an Annual Required Inspection. LPA met with Administrator Victoria and Benson De Los Reyes. LPA stated the purpose of the visit. A tour of the facility was conducted. COVID-19 guidelines are in place. Temperature check was observed upon entry. Facility has one entrance/exit point.

Facility appeared clean with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Bathrooms have trashcans with lid. Hand washing posters were observed by the kitchen and bathroom sink. Bedrooms were checked. The exterior tour was conducted.

LPA checked residents’ medications and observed a 30-day supply. Food supply was checked and there appeared to be an adequate supply. Cleaning and PPE supplies were checked. Facility staff was observed with mask on. Resident’s files have updated emergency contact information. Administrator certification is current.

No deficiencies were observed. Exit interview was conducted.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2022
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 1