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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200856
Report Date: 01/24/2024
Date Signed: 01/24/2024 04:22:07 PM

Document Has Been Signed on 01/24/2024 04:22 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:JOSEPH, CRYSTALYNFACILITY TYPE:
738
ADDRESS:24 W. CYPRESS PLACETELEPHONE:
(925) 392-0282
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 4CENSUS: 3DATE:
01/24/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Crystalyn Joseph, AdministratorTIME COMPLETED:
04:40 PM
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On 1/24/2024 at 3:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a health and safety check as a result of a priority 2 complaint. LPA met with Administrator, Crystalyn Joseph and informed her the reason for visit.

LPA toured facility including but not limited to the bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. Hot water temperature was measured at 110.6 degrees F in a hallway bathroom sink. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Client's medications were kept locked in the medication cart located in the staff office. Staff office is kept locked and require a key to enter. Carbon monoxide detectors were observed. Smoke detectors are interconnected with sprinkler system. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 3/3/2023. There are no accessible bodies of water observed. Indoor and outdoor passageways were free of obstruction.

No deficiencies are being cited on this date.

Exit interview conducted. A copy of this report was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2024
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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