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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200856
Report Date: 04/21/2026
Date Signed: 04/21/2026 03:42:35 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
04/14/2026 and conducted by Evaluator Tonica Syess-Gibson
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20260414140052
FACILITY NAME:CYPRESS HOUSEFACILITY NUMBER:
079200856
ADMINISTRATOR:MENDENHALL, JESSEFACILITY TYPE:
738
ADDRESS:24 W. CYPRESS PLACETELEPHONE:
(925) 392-0282
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY:4CENSUS: 3DATE:
04/21/2026
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Dejah Jordan, Assistant Administrator TIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff hit client in care
Staff restrained client in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 04/21/2026 at 10:45AM, Licensing Program Analyst (LPA), T. Syess-Gibson arrived unannounced to conduct the 10-day initial complaint investigation visit and deliver complaint findings for the allegations above. LPA met with Dejah Jordan and explained the reason for the visit.

During the investigation, LPA interviewed witness (W1) and staff (S1, S2, S3). LPA reviewed and obtained the following documents: Staff schedule, clients roster, C1’s admission agreements (Telecare and RCEB), identification and emergency information, physician’s report, Individual Behavior Support plan (IBSP), Medication Administration Record (MAR) Individual Program Plan (IPP), incident reports dated for the month of April 2026 and facility’s daily notes from 04/01/2026-04/19/2026.

Continue on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2026
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-20260414140052
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/21/2026
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
Continued from LIC9099


Staff hit client in care

Interview with W1 revealed C1 did not know the date or time of day when staff hit C1, interview with W1 also revealed that C1 did not know if staff were male or female. Interviews with S1, S2 and S3 revealed staff haven’t witnessed or been informed of any staff members hitting C1. Interviews with S1, S2 and S3 also revealed that when C1 does not take medications, C1 becomes agitated toward others and makes up stories that aren’t true. Record review revealed C1’s diagnoses can cause hallucination and delusional behaviors. Record review also revealed that C1 refused medications on 04/02/2026,04/03/2026,04/04/2026,04/14/2026,04/15/2026 and 04/19/2026.

Staff restrained client in care

Interview with W1 revealed C1 did not know the date or time of day when staff restrained C1, Interview with W1 also revealed that C1 also did not know if staff were male or female. Interviews with S1, S2 and S3 revealed staff haven’t witnessed or been informed of any staff members restraining C1. Interviews with S1, S2 and S3 also revealed that when C1 does not take medications, C1 becomes agitated toward others and makes up stories that aren’t true. Record review revealed C1’s diagnoses can cause hallucination and delusional behaviors. Record review also revealed that C1 refused medications on 04/02/2026,04/03/2026,04/04/2026,04/14/2026,04/15/2026 and 04/19/2026.

Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and a copy of report was given.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2