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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200856
Report Date: 05/17/2024
Date Signed: 05/17/2024 12:07:01 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
01/23/2024 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240123121944
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: 4DATE:
05/17/2024
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Crystalyn Joseph, AdministratorTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Facility staff pushed client resulting in serious injury.
INVESTIGATION FINDINGS:
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On 5/17/2024 at 9:55AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegation above. LPA met with Administrator, Crystalyn Joseph.

During the course of investigation, LPA interviewed 4 staff, witness, and complainants. LPA also obtained and reviewed client's files including: staff roster with contact information, staff schedule, admission agreement, physician's report, IPP, appraisal/care plan, emergency information, conservator documents, body check forms, incident reports, hospital documents, and medical records.

Interview with complainants revealed there was an incident where staff (S4) was alleged pushing client (C1) resulting in serious injury; however, complainants did not witness the incident and was verbally informed about the incident. Interview with staff indicated that S4 bumped into C1 during the incident and majority of the staff did not observe the incident. S7 stated staff observed C1 was fine after incident. (Continue on LIC9099C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024
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 2
Control Number 15-AS-20240123121944
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: 05/17/2024
NARRATIVE
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According to the facility's SIR (Special Incident Report), C1 was jumping and playing catching games with staff. Then, C1 started place items behind the entertainment center. S4 redirected C1 by verbal prompting to stop C1 from throwing items and intervened by jumping towards C1. Then S4 collided into C1 where C1 fell over and hit his head on the chair. Body check document indicated that C1 had a knot on the back of the head. C1's medical records states CT scan of the head reveals no evidence of acute intracranial blood and there's pronounced soft tissue swelling at the left posterior vertex without underlying fracture. C1 was stable for discharge on the same day.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted with Crystalyn Joseph. A copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2