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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200856
Report Date: 10/16/2025
Date Signed: 10/16/2025 03:31:52 PM

Substantiated


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
07/17/2025 and conducted by Evaluator Tonica Syess-Gibson
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250717163102
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:
10/16/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jennifer Rychlik, Lead Staff TIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Staff handled resident in a rough manner resulting in injury
Staff inappropriately shoved resident
INVESTIGATION FINDINGS:
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On 10/16/2025 at 10:00AM, Licensing Program Analyst (LPA), T. Syess-Gibson arrived unannounced to conduct an investigation and deliver complaint findings for the allegations above. LPA met with Jennifer Rychlik, Lead Staff, and explained the reason for the visit.

During the investigation, LPA interviewed complainant, staff members, reviewed and obtained documents.

Allegation: Staff handled resident in a rough manner resulting in injury
During the interviews with staff members, it was revealed that staff S3 were seen by S4 and S5 pulling C1’s ear, leaving redness and swelling. Record review revealed, licensee conducted an internal investigation and terminated S3 on 07/16/2025.

Continue on LIC9099C..
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
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-20250717163102
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: 10/16/2025
NARRATIVE
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Continued from LIC9099



Allegation: Staff inappropriately shoved resident
During the investigation, LPA interviewed complainant and staff members. Interviews with staff members, revealed that S4, S5 and S6 have witnessed S2 shoving, mistreating and verbally abusive to C1 while in care.



Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.



Exit interview conducted. Appeal rights and a copy of this report provided to Jesse.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20250717163102
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/17/2025
Section Cited
CCR
80065(l)
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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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Licensee terminated S3's assignment on 07/16/2025. Administrator agreed to email CCLD the facility's investigations notes by POC date.
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Based on interviews and record review the Licensee did not comply with the section cited above in make sure C1 free from abuse which poses a potential health and safety risk to person in care.
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Type B
10/23/2025
Section Cited
CCR
80072(a)(3)
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(a) Except for children’s residential shall have personal rights which include, but are not limited to, the following:(3)To be free from corporal or unusual punishment....
This requirement is not met

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Administrator agreed to have all staff trained by an authorized vendor on client abuse and send CCLD an email with training topic, participants names and signatures by POC date.
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Based on LPAs observation and record review the Licensee did not comply with the section cited above in make sure C1 free from corporal or unusual punishment, which poses a potential health and safety risk to person in care.
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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: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3