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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200856
Report Date: 10/04/2022
Date Signed: 10/04/2022 02:48:59 PM

Document Has Been Signed on 10/04/2022 02:48 PM - 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:SPIECKER, TIFFANY JFACILITY TYPE:
738
ADDRESS:24 W. CYPRESS PLACETELEPHONE:
(925) 392-0282
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 4CENSUS: 4DATE:
10/04/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:SPIECKER, TIFFANY J, Administrator TIME COMPLETED:
03:05 PM
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On 10/4/2022 at 2:00 PM, Licensing Program Analyst (LPA) L. Ibo conducted an unannounced Case Management in regard to Special incident report (SIR) received on 9/29/2022. Based on SIR, C1 engaged in dangerous behavior during a community outing with staff and another client. LPA met with Administrator Tiffany S. and explained the purpose of the visit.

LPA toured the facility inside and outside. LPA met with C1 and asked her few questions. LPA observed C1 was smiling during the interview, C1 stated she is “doing good”, C1 offered LPA if C1 can show her bedroom, LPA checked C1's bedroom. LPA did not observed any injury on C1 in related to the incident.

LPA interviewed Administrator, based on interview, C1 was out for shopping with 3 staff and another client, C1 cannot find the toy that she was looking for that is when C1 started to engaged in dangerous behavior. Staff was trained on how to handle C1’s behavior, 911 was called, C1 was placed on 72 hours hold at the hospital. Facility staff is continuing to monitor C1 at the facility and there is one on one staff in place.

No deficiencies cited.

Exit interview conducted with Administrator . A copy of report provided to care staff.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2022
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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