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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200856
Report Date: 05/06/2022
Date Signed: 05/06/2022 05:17:34 PM

Substantiated


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
04/20/2021 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20210420162047
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: 3DATE:
05/06/2022
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Xochit Munoz, Assistant Administrator;Kapioloni Singh, Direct care supervisorTIME COMPLETED:
05:45 PM
ALLEGATION(S):
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Facility is not following infection control
INVESTIGATION FINDINGS:
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On 5/6/2022 at 2:00PM, Licensing Program Analyst (LPA) L. Ibo conducted an unannounced complaint visit to delivered investigation finding. LPA met with staff Xochit Munoz, LPA explained the purpose of the visit. LPA called Administrator Athika Karolia , she stated that she is not available to meet with LPA, she gave permission to give copy of report to staff on duty.

Based on LPA’s observations, while LPA is touring the facility, staff does not properly wear mask, staff were wearing mask below their noses. LPA observed that staff are not wearing mask until LPA arrived at the facility.

The preponderance of evidence standard has been met; therefore, the above allegation(s) was found to be substantiated.Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.
Exit interview conducted. Appeal Rights and a copy of this report provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
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.
LIC9099 (FAS) - (06/04)
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Control Number 15-AS-20210420162047
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/13/2022
Section Cited
CCR
80072(a)(2)
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(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
This requirement is not mee as evidence by:
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Facility will train all staff on proper PPE, specifically on proper way of using mask and infection control guidelines. Facility will send topics use for training with all staff name and signature, documents need to be send to CCL by POC date.
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Based on observation, licensee did not comply with citation above this posed potential health and safety risk to client in care.
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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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
LIC9099 (FAS) - (06/04)
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