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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547204016
Report Date: 07/23/2024
Date Signed: 07/24/2024 07:17:14 AM

Document Has Been Signed on 07/24/2024 07:17 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:CYPRESS CARE HOME #1FACILITY NUMBER:
547204016
ADMINISTRATOR/
DIRECTOR:		DELOS REYES, VICTORIAFACILITY TYPE:
735
ADDRESS:1741 CYPRESS AVENUETELEPHONE:
(559) 688-8106
CITY:TULARESTATE: CAZIP CODE:
93274
CAPACITY: 6CENSUS: 5DATE:
07/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:34 AM
MET WITH:Victoria Delos Reyes, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On 07/23/24, Licensing Program Analyst (LPA) L. Salazar arrived to the facility unannounced to conduct the required Annual Inspection Visit. LPA was greeted by Administrator, stated the purpose of the visit and was allowed entry into the facility. Administrator provided a tour of the facility inside and out. Administrator on record is Victoria Delos Reyes , Certificate #6006747735, Exp. 11/23/25.

4 out of 4 residents in care were in day program at the time of visit. Facility is a 4 bedroom, 2 bathroom home. Residents bedrooms were observed to have the required lighting and furnishings and were free from odor and free from any passageway obstruction / fire hazards. Facility temperature was 76 degrees F.

Bathrooms were toured and observed to have operational lights, running water, and non- slip floors. Hot water temperature tested at 111 degrees F. Trash can with lid and hand washing postings were observed.

Medications were observed to be locked in a cabinet located in the kitchen. Cleaning supplies were observed to be locked in the garage. LPA toured the kitchen observed the required 7-day supply of non-perishable food and 2- day supply of fresh perishables to be properly stored.

Carbon monoxide and smoke detectors were tested and observed to be operational. Night lights were observed in the hallways. Fire Extinguisher was observed with a service date of 01/08/24. First aid kit was observed and contained all required items. Internet devices and a working phone line were observed to be available for residents in care.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: CYPRESS CARE HOME #1
FACILITY NUMBER: 547204016
VISIT DATE: 07/23/2024
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(Continued from 809)

The exterior tour of back yard was conducted and found to be free from debris. A covered outdoor seating area was observed for residents in care. Side gate was self-closing and self-latching.

Residents’ files were reviewed and observed to have update emergency contacts, Admission agreement, and current individual performance plans (IPP). A sample of staff files were also reviewed. Staff files were observed to have current First Aid/CPR. Staff are fingerprinted clear and associated to the facility.

Quarterly Emergency Disaster Drill logs were observed for staff. LPA observed the LIC 610D (Emergency Disaster Plan) with emergency numbers and evacuations locations was posted in the kitchen. Two appropriate shelter locations were identified to house individuals served by the facility.

All annual forms have been updated and received by Administrator, including infection control plan. An exit interview was conducted with Administrator. A copy of this report was discussed and provided at the time of visit. No deficiencies cited on today's visit.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC809 (FAS) - (06/04)
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