<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200856
Report Date: 02/16/2024
Date Signed: 02/16/2024 01:47:44 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
02/12/2024 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20240212103217
FACILITY NAME:CYPRESS HOUSEFACILITY NUMBER:
079200856
ADMINISTRATOR:JOSEPH, CRYSTALYNFACILITY TYPE:
738
ADDRESS:24 W. CYPRESS PLACETELEPHONE:
(925) 392-0282
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY:4CENSUS: 3DATE:
02/16/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Cyrstalyn Joseph, AdministratorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff left residents unsupervised
Staff yelled at residents
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 02/16/24 at 11AM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced visit, gathered information and delivered investigation findings to administrator (ADM). LPA explained the purpose of the visit with ADM. LPA observed the facility is a community crisis home for adults that serves Regional Center residents in need of crisis intervention services 24/7. ADM stated residents typically stay at the facility for crisis intervention for 18 months with the option for stay extensions if warranted.

During investigation, the Department obtained the following documents from the facility – personnel record, residents’ roster, admission agreements, emergency information, physician’s reports, IPP, appraisal/care plans, residents’ data tracker logs, face sheets, incident reports.
Continued on next page, LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
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 3
Control Number 15-AS-20240212103217
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: 02/16/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: Staff left residents unsupervised
Investigation Finding: Unsubstantiated
During investigation, staff (ADM, S1, S2, S3) denied leaving residents (R1, R2, R3) unattended or unsupervised. Review of residents (R1, R2, R3) individual care plans showed they required constant monitoring, redirecting and supervision by certified/trained staff due to propensity for aggressive behaviors (biting, ripping clothes, smearing feces, throwing things and throwing up body fluids). Daily data 15-minute tracker logs showed residents were closely monitored and checked by staff 24/7. Recorded daily data tracking logs showed R1 has 3:1 staff ratio while the other 2 residents (R2, R3) were monitored with 1:1 staff ratio. Residents’ activities were documented every 15 minutes on the daily tracking log which showed their daily activities a the facility. LPA observed R2 has echolalia and would tend to repeat what is said. R1 was not available for interview because he was at day program during visit.

Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff left residents unsupervised and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff left residents unsupervised is unsubstantiated.

Continued on next page, LIC 9099-C1
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20240212103217
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: 02/16/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: Staff yelled at residents
Investigation Finding: Unsubstantiated
D)f staff (ADM, S1, S2, S3, S4) documents showed they are Board Certified Behavior Analysts (BCBA) and crisis prevention trained service professionals (CPI) in properly redirecting and managing residents with aggressive behaviors. Review of residents (R1, R2, R3) care plans showed they have a propensity for aggressive behaviors (biting, ripping clothes, throwing things, smearing feces and throwing up body fluids). LPA did not observe any staff yelling or screaming at residents (R1, R2, R3). ADM stated that staff would use crisis intervention words such "Stop, Calm Body, Safe hands" to ensure residents are redirected in a safe manner.

Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff yelled at residents and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff yelled at residents is unsubstantiated.

No deficiencies observed during visit.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3