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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200856
Report Date: 10/26/2021
Date Signed: 10/26/2021 12:52:34 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/10/2020 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20201110115353
FACILITY NAME:CYPRESS HOUSEFACILITY NUMBER:
079200856
ADMINISTRATOR:KEMP, KELSEYFACILITY TYPE:
738
ADDRESS:24 W. CYPRESS PLACETELEPHONE:
(925) 392-0282
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY:4CENSUS: 4DATE:
10/26/2021
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Athika Karolia & Xochit MunozTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Licensee did not safeguard resident's personal property
Licensee did not report resident's change of condition to responsible party
INVESTIGATION FINDINGS:
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On 10/26/2021 Licensing Program Analyst (LPA) L. Ibo arrived unannounced to deliver the findings on the above allegations. LPA met with S3, staff. S3 called covering Administrator Athika Karolia, Administrator, who arrived after about 40 minutes. LPA informed Administrator the purpose visit.

LPA conducted records review, based on LIC621 all belongings were returned to responsible party (RP). Based on LIC621 there were 2 backpacks listed as returned to RP, however upon admission there were no 2 backpacks listed on the report, there is no way for the LPA to verify if these backpacks were the same as the missing items on the complaint allegation.

...Continue to LIC90999...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20201110115353
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: CYPRESS HOUSE
FACILITY NUMBER: 079200856
VISIT DATE: 10/26/2021
NARRATIVE
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LPA conducted records reviews and interview. Based on records review on Special incident reports (SIR) for C1, it was documented that all RPs were informed on the hospitalization, change of condition or any special incident occurred to C1. According to Administrator the process of reporting to RPs are; if the client has any SIRs the case managers, conservators, community care licensing, regional center of east bay and family members are informed within 24hrs, if and when the client stayed at the hospital, it is the hospital’s responsibility to contact the emergency contact information listed on the client’s profile for any change of condition.

Based on interviews and documentation reviewed the above allegations are UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2