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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200856
Report Date: 03/05/2024
Date Signed: 03/05/2024 01:31:17 PM

Document Has Been Signed on 03/05/2024 01:31 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
OAKLAND ASC, 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:
03/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Bridget NamitalaTIME COMPLETED:
01:40 PM
NARRATIVE
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On 03/05/2024 at 10:25 AM, Licensing Program Analysts (LPAs)Tonica Syess-Gibson and L. Hall unannounced annual required inspection. LPAs met with Crystalyn Joseph and explained the purpose of the visit. Administrator Crystalyn Joseph, arrived at 10:55AM. LPAs toured the facility with Administrator Crystalyn Joseph. The facility’s fire clearance was approved for Four (4) Non-Aambulatory clients.

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of four (4) total bedrooms and two (2) bathrooms. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 69 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 113.3 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: CYPRESS HOUSE
FACILITY NUMBER: 079200856
VISIT DATE: 03/05/2024
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Continued from LIC809.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 03/03/2023. Emergency Disaster Plan was last posted on 01/16/2024. First aid kit was observed to be complete. Fire drill was last conducted on 02/08/2024.

Three (3) staff records reviewed and complete. All Three (3) clients records reviewed, current, and complete.LPAs also reviewed P & I and medication.

The following forms to be updated and submitted to CCLD by 03/12/2024:

· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 402 Surety Bond
· LIC308 Designation of facility responsibility

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/05/2024 01:31 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 03/05/2024 at 12:49 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CYPRESS HOUSE
FACILITY NUMBER: 079200856

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in not having a TB and Health Scrrening for S2 and S3 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/15/2024
Plan of Correction
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Administrator agreed to have S2 and S3 obtain an Health and TB screening and submit a copy to CCLD by the POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024


LIC809 (FAS) - (06/04)
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