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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200856
Report Date: 01/25/2023
Date Signed: 01/25/2023 04:24:02 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/23/2021 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20210623151508
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: 3DATE:
01/25/2023
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Tifanny Spiecker, Administrator TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility did not follow reporting requirements.
INVESTIGATION FINDINGS:
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On 01/25/2023 at 10:15AM, Licensing Program Analysts (LPA) L. Ibo and L. Fici arrived unannounced to deliver findings for the above allegation. LPAs met with S2 and informed her the purpose of the visit. Administrator Tiffany Spiecker arrived at the facility around 11:50AM.

During the course of investigation, LPAs conducted records review and interview. Records review revealed that facility did not submit special incident report to Community care licensing (CCL) pertaining to R1’s behavior on 6/19/2021. Staff admitted that Special incident report (SIR) was completed, sent to facility team members and filed on the facility binder but was not sent to CCL.

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809D. Deficiencies and plan and proof of corrections were discussed.
Exit interview conducted. Appeal Rights and copy of this report provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/23/2021 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20210623151508

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: 3DATE:
01/25/2023
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Tifanny Spiecker, Administrator TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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9
Staff inappropriately handled resident.
INVESTIGATION FINDINGS:
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On 01/25/2023 at 10:15AM, Licensing Program Analysts (LPA) L. Ibo and D. Fici arrived unannounced to deliver findings for the above allegations. LPA met with S2 and informed her the purpose of the visit. Administrator Tiffany Spiecker arrived at the facility around 11:50AM.

During the course of investigation, LPAs conducted records review and interview. Based on records review from the facility files (incident reports) that R1 being aggressive towards himself and to others, but report did not indicate any staff inappropriately handled R1. Interview revealed that R1 did was not sent out to hospital (Kaiser) but rather to another institution in Martinez Ca.

...Continue to LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20210623151508
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: CYPRESS HOUSE
FACILITY NUMBER: 079200856
VISIT DATE: 01/25/2023
NARRATIVE
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Based on R1’s Individual behavior support plan (ISP), one of R1’s behavior was false allegation against staff.

Based on staff interview, they are not aware of any staff handling anyone roughly. Staff stated that they have not witnessed or heard any staff acting inappropriate behavior towards clients in care. R1 no longer live at the facility. LPAs also attempted to interview other clients, but clients did not answer LPA’s questions.

LPAs observed during the visit that clients are comfortable, well dressed and staff are attending to each clients in care.

Based upon the information obtained during investigation. The above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

Exit interview conduct and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20210623151508
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CYPRESS HOUSE
FACILITY NUMBER: 079200856
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/03/2023
Section Cited
CCR
80061(b)
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Reporting Requirements: Upon the occurrence… of any of the events specified…a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report …. shall be submitted to the licensing agency within seven days.......
This requirement is not met as evidenced by:
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Administrator agreed to conducted in-service training regarding regulation cited above. Administrator will need to submit copy of training topic, staff names and staff signature on POC date.
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Based on interview, licensee did not comply with the above Regulation by failing to submit incident reports to CCL which poses potential health, safety and personal right risks to persons 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: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4