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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200856
Report Date: 02/23/2023
Date Signed: 02/23/2023 03:37:54 PM

Document Has Been Signed on 02/23/2023 03:37 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:
02/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:SPIECKER, TIFFANY, ADMINISTRATORTIME COMPLETED:
03:55 PM
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On 02/23/2023 at around 2:05PM, Licensing Program Analyst (LPA) L. Ibo conducted an infection control annual inspection and met with Administrator Tiffany Spiecker, LPA informed her the purpose of the visit. The facility is licensed as Community Crisis Home – ARF. LPA observed 1 client at the living room area, 1 client outside with facility staff and other two clients are in their rooms.

LPA inspected the facility inside and outside. LPA observed COVID-19 signage posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Pathways were observed to be free of obstruction and fire hazards. Facility has a completed mitigation plan and infection control plan.

Infection control designated leader is the Administrator. There was at least 7 days of nonperishable and 2 days of perishable foods. Facility room temperature was maintained at 70 degrees Fahrenheit. A certified Administrator is on site a minimum of 20 hours a week to oversee proper business operation. Smoke and Carbon monoxide detectors were operational.

No deficiency cited during the visit.

Exit interview conducted copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2023
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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