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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200856
Report Date: 10/26/2021
Date Signed: 10/26/2021 12:45:48 PM

Document Has Been Signed on 10/26/2021 12:45 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:KEMP, KELSEYFACILITY TYPE:
738
ADDRESS:24 W. CYPRESS PLACETELEPHONE:
(925) 392-0282
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 4CENSUS: 4DATE:
10/26/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:23 PM
MET WITH:Athika Karolia & Xochit MunozTIME COMPLETED:
01:30 PM
NARRATIVE
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On 10/26/2021 Licensing Program Analyst (LPAs) L. Ibo arrived unannounced to conduct case management visit in related to another visit conducted.

During the facility inspection tour, at 10:45AM LPA observed Fabuloso disinfectant cleaner accessible to clients in care, LPA informed the staff regarding the observation. Staff then locked the disinfectant cleaner.

Deficiency is cited from Title 22 California Code of Regulations (see 9099D). Failure to submit proof of correction (POC) by plan of correction due date and any repeat violations within 12-month period may result in civil penalties.



Deficiency and plan and proof of correction were discussed with Administrator.

Exit interview conducted. Appeal Rights and copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2021
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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Document Has Been Signed on 10/26/2021 12:45 PM - It Cannot Be Edited


Created By: Leslie Ibo On 10/26/2021 at 12:30 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: 10/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/26/2021
Section Cited
CCR
80087(g)

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80087 Buildings and Grounds (g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidence by:
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Staff locked the disinfectant right away.

Deficiency was cleared during the visit.

Facility needs to conduct an in-service training for all staff to review the regulation that was cited under.
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Based on LPAs observation, licensee did not comply with the section cited above LPA observed disinfectant cleaner accessible to clients in care which poses an immediate health and safety risk to clients in care.
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Proof of training by 11/5/2021.

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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:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2021


LIC809 (FAS) - (06/04)
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