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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801811
Report Date: 04/24/2026
Date Signed: 04/24/2026 03:02:58 PM

Document Has Been Signed on 04/24/2026 03:02 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:CYPRESS GARDEN HOME CAREFACILITY NUMBER:
405801811
ADMINISTRATOR/
DIRECTOR:		GABRIELA SOOFACILITY TYPE:
740
ADDRESS:824 JACANA COURTTELEPHONE:
(805) 904-6282
CITY:ARROYO GRANDESTATE: CAZIP CODE:
93420
CAPACITY: 6CENSUS: 4DATE:
04/24/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Karoly "Robert" Budai, Back up AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) De Leon arrived at 10:15am to conducted a 1 year annual visit to the facility above. LPA met with back up to Administrator Robert Budai and explained the purpose of the visit.

A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit:

Infection Control: The facility has submitted a current Infection Control Plan. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. Facility staff need to be trained upon hire and annually thereafter on infection control and plan.

Physical Plant & Environment Safety: The facility is a 5 bedroom with 2 on suite bathrooms and 1 main restroom for residents, staff and visitors. The facility currently occupies 4 residents, and is staffed with 4 staff and 2 administrators. The facility is clean, safe and sanitary. The pathways are clear of any obstructions. The facility has sufficient space inside and outside for activities and visiting. The gates are self-closing and self-latching. The facility has outdoor furniture for residents use with shaded area. Laundry room has working washer and dryer. Water was tested in the main restroom measured at 152.2 F, Administrator turned down water heater and LPA at end of visit tested and measured at 143.6, Administrator adjusted the water heater and will check temperature again and adjust if needed.

Operational Requirements: The Facility is operating in compliance with fire clearance. The facility provided current liability insurance valid till 06/15/2026. The fire clearance is granted for 6 non-ambulatory, of which 1 may be bedridden. Hospice wavier granted for 4. Continued 809-C
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Rachael De Leon
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: CYPRESS GARDEN HOME CARE
FACILITY NUMBER: 405801811
VISIT DATE: 04/24/2026
NARRATIVE
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Staffing: The facility employes 4 staff and 2 Administrators. Staff records are kept confidential. Staff records were reviewed for 4 staff and 2 Administrators. 2 out of 6 records had fingerprint clearance and associations with criminal record statements, personnel record or application, First Aid and CPR certificates and Health screening with TB results. All records had fingerprint clearances, 1st Aid and CPR. Administrator file was reviewed for continuing education which was not available for review. Administrator Certificate expired 04/18/2026 and other administrator certificate was verified on CCL pending list.
Personnel Records & Training: The facility keeps confidential binder with taps for each staff member. Files lacked training hours and subjects for 2025-2026 for 20 hours. Some staff had training records but did not met the required hours and new staff files need 40 hours of initial training.
Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Four Files were reviewed for signed Admission Agreements, Medical Assessments LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. Files were current and up to date.
Resident Rights Information: All require postings were posted in common areas of facility. Personal rights, Theft and Loss policy, Nondiscrimination notice, CCL Complaint poster is posted on entry and LTCO poster is posted in the dining room.
Planned Activities: The facility offers activities to all residents in care. Activities include books, magazines, newspapers, TV watching, daily walks, group discussions and communications, and puzzles. The facility has sufficient space to allow for activities indoors and outdoors.
Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available in the garage.
Incidental Medical & Dental: Facility provides transportation or assist in providing transportation to medical and dental appointments when needed. The medications records were reviewed for all 4 residents in care. Each Residents has a Medication Administration Records (MAR) and the Centrally Stored Medication and Destruct Records (CSMDR). LPA completed a full audit of residents medication, all medications were stored in the original containers, prescription labels were not altered, and no medications were expired. Doctors orders were present in resident files.

Continued 809-C
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Rachael De Leon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2026
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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: CYPRESS GARDEN HOME CARE
FACILITY NUMBER: 405801811
VISIT DATE: 04/24/2026
NARRATIVE
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Disaster Preparedness: The current emergency disaster forms were posted. The facility did not have disaster drills quarterly for 2026 year. The fire extinguishers were charged. The dual smoke and carbon monoxide detectors are present and hard wired throughout the facility. The facility has disaster supplies present with extra food and water.

Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked separately in cupboards. The facility does have 1 hospice residents in care, care plan is up to date and present. The facility does have one Home Health resident in care, home health plan is present and kept up to date. The facility does not have any current residents on oxygen. The facility has exiting door alarms, tested and working properly. The facility does not have delayed egress, secured perimeters with locked gates or doors.


Exit interview conducted, deficiencies cited, copy of report and appeal rights printed for Administrator.
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Rachael De Leon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2026
LIC809 (FAS) - (06/04)
Page: 4 of 64
Document Has Been Signed on 04/24/2026 03:02 PM - It Cannot Be Edited


Created By: Rachael De Leon On 04/24/2026 at 02:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CYPRESS GARDEN HOME CARE
FACILITY NUMBER: 405801811

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in the facility main restroom water tempearture was tested and measured 152.2 F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/27/2026
Plan of Correction
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Administrator adjusted the water heater at visit, will retest water tomorrow and make any needed adjustments and provide a 7 day log to CCL of water tempeatures with in requirements of regualtion 105-120 degress Farnheit. Provide log to CCL.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Rachael De Leon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/24/2026 03:02 PM - It Cannot Be Edited


Created By: Rachael De Leon On 04/24/2026 at 02:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CYPRESS GARDEN HOME CARE
FACILITY NUMBER: 405801811

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(13)(B)1
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e). 1. For Certified Administrators, a copy their current and valid Administrative Certification meets this requirement.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above in 2 Administrator did not have a current file at the facility and niether administrator ceritifcate was valid on visit which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2026
Plan of Correction
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Administrator agreed to get files for all administrator and staff present at the facility and will call the administrator ceritircate bearu to follow up on the pending application and submitting a renewal applciation. Send a photo of files and valid certificates.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Rachael De Leon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/24/2026 03:02 PM - It Cannot Be Edited


Created By: Rachael De Leon On 04/24/2026 at 02:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CYPRESS GARDEN HOME CARE
FACILITY NUMBER: 405801811

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 out of 4 files reviewed did not meet the requirement of hours or subjuect matter for 2025-2026 annual which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2026
Plan of Correction
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Administrator agreed to have all staff take initials 40 hours or annual 20 hours for the 2026 annual training year. Provide proof of trianing for 4 staff with required hours and subjects to CCL.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Rachael De Leon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2026


LIC809 (FAS) - (06/04)
Page: 7 of 64
Document Has Been Signed on 04/24/2026 03:02 PM - It Cannot Be Edited


Created By: Rachael De Leon On 04/24/2026 at 02:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CYPRESS GARDEN HOME CARE
FACILITY NUMBER: 405801811

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in the facility did not have any records of quarterly disaster drills for the 2 quaters in 2026, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2026
Plan of Correction
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Administrator agreed to do 2 quarterly disaster drills for 2026 and provide proof of those drills to CCL.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Rachael De Leon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2026


LIC809 (FAS) - (06/04)
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