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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200856
Report Date: 01/19/2022
Date Signed: 01/19/2022 11:56:28 AM

Document Has Been Signed on 01/19/2022 11:56 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:CYPRESS HOUSEFACILITY NUMBER:
079200856
ADMINISTRATOR:KEMP, KELSEYFACILITY TYPE:
738
ADDRESS:24 W. CYPRESS PLACETELEPHONE:
(925) 392-0282
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 4CENSUS: 2DATE:
01/19/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Kapiolani SIngh, Care StaffTIME COMPLETED:
12:20 PM
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On 1/19/2022 at 11:20 AM, Licensing Program Analyst (LPA) L. Francisco conducted a Case Management while at the facility for another matter to obtain additional information regarding the current outbreak. LPA met with Care Staff Kapiolani Singh and spoke to Administrator, Athika Karolia over the phone.

Based on information obtained, facility coordinated with Regional Center of East Bay and Department of Developmental Services (DDS), and transferred two clients to skilled nursing facility. Facility currently has sufficient staffing to meet the 2 clients needs at facility.

No deficiencies cited. Exit interview conducted with Administrator over the phone and authorized care staff to sign report. A copy of report provided to care staff.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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