<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200856
Report Date: 04/05/2023
Date Signed: 04/05/2023 11:51:58 AM

Unsubstantiated


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
07/29/2021 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20210729160216
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:
04/05/2023
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Cyrstalyn Joseph, new AdministratorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff hit resident
Facility staff handled resident in a rough manner
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 4/5/2023 at 9:20 AM, Licensing Program Analysts (LPA) L. Ibo arrived unannounced to deliver findings for the above allegations. LPA met with new Administrator Crystalyn Joseph and informed her the purpose of the visit.

During the course of investigation, LPA conducted staff and client’s interview, obtained and reviewed documents including physician's report, care plan, individual program plan, emergency information, and client notes.

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

DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023
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 2
Control Number 15-AS-20210729160216
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: 04/05/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Facility staff hit resident

During the course of investigation, LPA L. Ibo interviewed clients in care, based on interview clients denied any incident regarding the above allegation. LPA attempted to interview C1, however C1 was no longer live at the facility. Based on interview with staff, they denied witnessing or knowing any staff that hit the clients in care. There were no witnesses to the incident.

Facility staff handled resident in a rough manner

Based on staff and client interview, staff are not aware of any staff handling clients in roughly manner. Staff stated that they have not witnessed or heard any staff acting inappropriate behavior towards clients in care. C1 no longer live at the facility. Clients denied witnessing or hearing any staff handling clients in rough manner.



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

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED.



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

DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2