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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200856
Report Date: 05/06/2022
Date Signed: 05/06/2022 05:18:38 PM

Document Has Been Signed on 05/06/2022 05:18 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: 3DATE:
05/06/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Xochit Munoz, Assistant Administrator; Kapioloni Singh, Direct care supervisorTIME COMPLETED:
03:30 PM
NARRATIVE
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On 5/6/2022 at 2:00PM, LPA visited the facility to deliver complaint findings, while LPA was at the facility a case management visit was conducted. LPA toured facility inside and outside.

LPA observed the following:

At Approximately 2:15PM LPA observed that clients cabinets was not in good condition, drawers were detached and there is also one cabinet where only two drawers was left.

At approximately 2:20PM LPA toured the facility with S3, LPA observed that chemicals were accessible with clients in care.

At approximately 4:00PM LPA observed hallway light was not functional.


Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2022
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 05/06/2022 05:18 PM - It Cannot Be Edited


Created By: Leslie Ibo On 05/06/2022 at 04:30 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: 05/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/06/2022
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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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 5/10/2022
Type B
05/20/2022
Section Cited
CCR80087(a)

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80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidence by:

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Facility need to provide a functional cabinet drawers to all clients in care, facility need to provide proof of purchase or picture of current cabinet drawers that are fix.
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Based on LPA observation, licensee did not comply with the section cited above, LPA observed, hallway light is not functional, client's cabinet drawers was in disrepair, which posed potential health and safety risk to clients in care.
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Facility needs to send proof of maintenance record stating fixture of hallway light.
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: 05/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2022


LIC809 (FAS) - (06/04)
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