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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200856
Report Date: 05/29/2024
Date Signed: 05/29/2024 03:52:02 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
04/18/2024 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 15-AS-20240418152308
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:
05/29/2024
UNANNOUNCEDTIME BEGAN:
03:03 PM
MET WITH:Crystalyn Joseph, AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff handled resident in an inappropriate manner.
INVESTIGATION FINDINGS:
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On 5/29/2024 at 3:00PM, Licensing Program Analysts (LPAs), Carol Fowler and Tonica Syess-Gibson arrived unannounced to deliver complaint findings for the allegations above. LPAs met with Crystalyn Joseph, Administrator, and explained the reason for the visit.

It was alleged that on 4/15/2024, a Direct Care Staff handled resident in an inappropriate manner. During the course of the Department's investigation, staff interviews were conducted, and relevant documents were reviewed. Interviews with staff revealed that C1 has a 3 on 1 staff team. Staff stated C1 was escalated the entire day, while in C1’s room C1 wanted C1’s pants which were in the dryer. Staff stated that S1 informed C1 that C1’s pants are in the dryer can’t you wait.
Continue on LIC 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024
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-20240418152308
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: 05/29/2024
NARRATIVE
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Continue from LIC 9099

Staff then witnessed C1 walk up to S1 and vomited in S1 face. S1 stated that S1 stood up and wiped S1 eyes and S3 helped S1 to the bathroom. S3 stated that when C1 vomited in S1 face S1 stood up and was wiping S1 eyes and S1 hand touched C1 and it may have been S1 reflexes, S3 stated that S3 helped S1 to the door leading to the hallway, S3 remained in the room with C1. Staff stated that S4 was sitting next to the door on the phone (FaceTime). S4 stated that C1 vomited in S1 face and S1 stood up wiped the vomit from S1 eyes and then slapped C1 and asked why did you do that. S4 also stated after the incident that S4 called the Administrator to report the incident. S2 stated that S2 was in the restroom at the time of the incident and saw S1 cleaning up and asked what happened, at that time S1 reported that C1 vomited in S1 face while trying to keep C1 calm in C1 room. S4 reported the incident to S2 and informed S2 that S1 slapped C1 in the face.

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: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20240418152308
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: 05/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/14/2024
Section Cited
CCR
80065(I)
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Personnel Requirements. (l) Personnel shall provide for the care and safety of persons without physical or verbal abuse, exploitation or prejudice. This requirement is not met as evidenced by:
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Administrator agreed to conduct in-service training on Crisis Management for all staff.

Administrator will submit sign in sheet to the Department by the POC date.
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S1 handling C1 iappropriate manner. not providing care and safety without physical abuse. Administrator put S1 on Administrative leave and has been termanited. n Staff handled resident in an in
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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: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024
LIC9099 (FAS) - (06/04)
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