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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200856
Report Date: 05/22/2024
Date Signed: 05/22/2024 11:24:27 AM

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
04/09/2024 and conducted by Evaluator Carol Fowler
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240409085336
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:
05/22/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:KYLE LIDDLE, DIRECT CARE SUPERVISORTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff handled resident in a rough manner
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 5/22/2024 at 10:00AM, Licensing Program Analysts (LPAs), Carol Fowler and Tonnica Syess-Gibson arrived unannounced to deliver complaint findings for the allegations above. LPA met with Kyle Liddle, Direct Care Supervisor, and explained the reason for the visit.

It was alleged that on 4/6/2024, a Direct Care Staff handled resident in a rough manner. During the course of the Department's investigation, resident and staff interviews were conducted, relevant documents were reviewed, and observations were made. Interviews with witnesses revealed that C1 was pulled by C1 ankles dragging C1 bare buttock down the hallway. Interview with S1 revealed that S1 was called into the facility to help because the facility was short staffed, and in a crisis situation with a unrelated client.

CONTINUE ON LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024
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-20240409085336
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: 05/22/2024
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
CONTINUE FROM LIC9099

C1 had gotten into the office and was on the floor, S1 stated that S1 pulled C1 out of the office on a blanket and staff closed the door of the office once C1 was removed. Interview with S2 revealed that C1 was on the floor in the office and witnessed S1 grab C1 by the ankles and pulled C1 out of the office by C1’s ankles on C1’s bare buttock. Interview with S3 revealed that S1 had C1 by the ankles pulling C1 on C1’s bare buttocks on the floor down the hallway. C1 had gotten into the office and was on the floor, S1 stated that S1 pulled C1 out of the office on a blanket and staff closed the door of the office once C1 was removed. Interview with S2 revealed that C1 was on the floor in the office and witnessed S1 grab C1 by the ankles and pulled C1 out of the office by C1’s ankles on C1’s bare buttock. Interview with S3 revealed that S1 had C1 by the ankles pulling C1 on C1’s bare buttocks on the floor down the hallway.

Based on LPAs observations, interviews conducted, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulation, Title 22 is cited on the LIC 9099D.



An exit interview conducted, and a copy of appeal rights left and discussed with the Administrator.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 15-AS-20240409085336
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: 05/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/05/2024
Section Cited
CCR
80065(I)
1
2
3
4
5
6
7
Personnel Requirements. (l) Personnel shall provide for the care and safety of persons without physical or verbal abuse, exploitation or prejudice.
1
2
3
4
5
6
7
Administrator agreed to conduct in-service training on Abuse and Neglect for all staff.

Administrator will submit sign in sheet to the Department by the POC date.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: S1 handling C1 in a rough manner, not providing care and safety without physical abuse. (Administrator put S1 on Administrative leave (suspension)
8
9
10
11
12
13
14
on 4/9/2024. S1 has returned to work). Which poses a health and safety risk to residents in care.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3