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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881605
Report Date: 01/09/2025
Date Signed: 01/09/2025 11:09:58 AM

Document Has Been Signed on 01/09/2025 11:09 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CYPRESS SPRINGS HOMECAREFACILITY NUMBER:
331881605
ADMINISTRATOR/
DIRECTOR:		NUGUID, SUSAN LFACILITY TYPE:
740
ADDRESS:68905 HERMOSILLO ROADTELEPHONE:
(760) 459-3214
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY: 6CENSUS: 0DATE:
01/09/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Susan Nuguid, applicantTIME VISIT/
INSPECTION COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Seo Jeon made an announced visit to the facility for the purpose of conducting a pre-licensing inspection. LPA met with Applicant, Susan Nuguid, who accompanied LPA for the inspection. The Applicant has submitted an application for 6 residents (6 non-ambulatory). On 6-18-2024, the Riverside County Fire Department approved a fire clearance for which the applicant has applied for.

The facility is a single story home consisting of 5 bedrooms, 4 bathrooms, kitchen, dining room, family room, garage, backyard with a covered patio, and a locked shed that is being used for storage. There is no swimming pool on the premises. The bedrooms were observed to have bed, lighting, night stand, chest of drawers and area for sitting. The bathrooms had nonskid mats, and grab bars. There is plenty of extra linen (sheets, blankets, towels) that were observed to be in good repair. The smoke and carbon monoxide detectors were tested and found to be operable.

The hot water temperature was tested and was found to be within regulatory limits measuring at 109 degrees Fahrenheit. The facility is equipped with flashlights, night lights and solar panels. The facility has an emergency disaster plan, dementia plan and infection control training plan on file.

The facility has a sufficient supply of dishes, cooking and eating utensils, that were observed to be in good repair. The facility food supply was observed to be sufficient as there was 2-day supply of perishable and a 7-day supply of nonperishable food items. The facility has an emergency food and water supply.

Continued on LIC809-C....
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CYPRESS SPRINGS HOMECARE
FACILITY NUMBER: 331881605
VISIT DATE: 01/09/2025
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The passageways, and ramps/inclines are clear and free from obstruction. The home has 1 fully charged fire extinguisher. The facility does not have any known guns or ammunition stored on grounds. The sharps/knives are stored in a locked cabinet in kitchen. The medications will be kept in individual boxes that will be stored in a locked cabinet located in living room. There is a fully stocked first aid kit with manual.

LPA observed the required postings (facility sketch, resident council, theft and loss policy, personal rights, PUB475 CCL/dept complaint poster and the Long term Care Ombudsman poster) in the kitchen wall.

The facility was observed to have activities to encourage socialization like various board games as well as a covered patio with plenty of outdoor space for walking and physical activities.

LPA observed that the physical plant is clean, in good repair, and to be hazard-free during today’s visit. LPA determined the facility meets the operational requirements for licensure. The Pre-licensing inspection is complete, and this facility has no deficiencies.

An exit interview was conducted, and this report was discussed and provided to applicant, Susan Nuguid.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC809 (FAS) - (06/04)
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