079200856-4-23-2025-15-AS-HHUL-DGFKVS-20250507081449

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200856
Report Date: 04/23/2025
Date Signed: 04/23/2025 04:28:16 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
01/06/2025 and conducted by Evaluator Tonica Syess-Gibson

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20250106161008

FACILITY NAME:	CYPRESS HOUSE		FACILITY NUMBER:	079200856
ADMINISTRATOR:	JOSEPH, CRYSTALYN		FACILITY TYPE:	738
ADDRESS:	24 W. CYPRESS PLACE		TELEPHONE:	(925) 392-0282
CITY:	OAKLEY	STATE: CA	ZIP CODE:	94561
CAPACITY:	4	CENSUS: 2	DATE:	04/23/2025
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Crystalyn Joseph, Administrator		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Staff neglected client.
Staff inappropriately handled client
Staff was verbally aggressive towards client
Staff mismanaged client's medication

INVESTIGATION FINDINGS:

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On 04/23/2025 at 2:45pm, Licensing Program Analyst (LPA), T. Syess-Gibson arrived unannounced to deliver complaint findings for the allegations above. LPA met with Crystalyn Joseph, Administrator and explained the reason for the visit.

During the investigation, LPA interviewed three (3) staff members (ADM, S1 and S2), witness (W1). LPA requested the following documents (staff roster with contact information, resident roster, C1’s Individual Behavior Support Plan (IBSP) dated January 13, 2025, C1’s Medication Administration Record (MAR),Special Incident Reports (SIRs), and Cypress House investigation against staff).

Continue on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025

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-20250106161008

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CYPRESS HOUSE	FACILITY NUMBER: 079200856
	VISIT DATE: 04/23/2025

NARRATIVE

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Continued from LIC9099

Allegation: Staff neglected client
During the investigation, W1 stated during interview, W1 witnessed staff member disrupted C1’s environment by moving C1’s mattress to the floor and rearranging of furniture. W1 says the last time she read the client’s individualization Behavior Support Plan (IBSP) was when C1 was admitted to Cypress House a couple of years ago. S1, S2, and S3 stated during interview C1 IBSP addresses the removal of mattress from the bed to the floor when C1 is having a behavior and wants the mattress removed. Staff also stated, C1 has likes to remove his mattress from the bed and place on the floor to sleep. LPA reviewed C1’s IBSP dated January 13,2025 which indicated rearranging of furniture (mattress) is okay when C1 is having a behavior and demands the mattress to be moved. LPA observed the plan was approved by C1’s Behaviorist, Regional Center of East Bay (RCEB), Telecare, DDS and client’s rights (CR).

Allegation: Staff inappropriately handled client
During the investigation, W1 stated she didn’t witness any inappropriate handling towards client (C1) and that her staff did. LPA was unsuccessful in interviewing the other hillside staff members. S1 and S2 added that after C1 had an episode (vomiting), they both placed C1 in the shower and dressed C1 with clean clothing, prior to leaving the facility. S1 and S2 also stated during interview, has not witnessed any staff members inappropriately handling any clients in care and that all of the staff at cypress follows C1's IBSP.

Allegation: Staff was verbally aggressive towards client
During the investigation, W1 stated she witnessed staff being verbally aggressive towards C1 by yelling at C1 when C1 was having a behavior. S1 stated during the interview staff’s interactions with C1 are all based on C 1’s IBSP, and the ongoing training Telecare provides to staff on a regular basis. S1 also stated, the facility staff and are support team for C1 works hard and meet regularly to implement plans that would work for C1. LPA reviewed C1’s IBSP and it revealed that staff should use a firm, but calm voice as part of C1’s interventions.

Continue on LIC9099C

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20250106161008

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CYPRESS HOUSE	FACILITY NUMBER: 079200856
	VISIT DATE: 04/23/2025

NARRATIVE

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Continued from LIC9099C

Allegation: Staff mismanaged client's medication
During the investigation, W1 stated she witnessed S1 preparing C1’s medication and the cup tipped over, one pill fell behind the med cart, and the other fell on the med cart. W1 continued to state S1 placed medications back into the cup and asked W1 to administer the meds, W1 admitted to administering the medication as instructed. During interview with S1, S1 stated the medication did not hit the floor, one pill fell onto the med cart, and S1 placed it back into the cup to be administered. LPA reviewed the Medication Administration Record (MAR) and verified the medications was administered to C1.

No deficiencies cited during visit.

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

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025

LIC9099 (FAS) - (06/04)

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