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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200856
Report Date: 04/05/2023
Date Signed: 04/05/2023 11:56:41 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
01/31/2022 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20220131141600
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:
11:06 AM
MET WITH:Crystalyn Joseph, New AdministratorTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Staff are not wearing proper PPE at night.
Staff are sleeping on the NOC shift.
There are no lights in the hallways at night and There are no lights in the bathrooms at night.
INVESTIGATION FINDINGS:
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On 4/5/2023 at around 11:05 AM, Licensing Program Analyst (LPA) L. Ibo conducted an unannounced complaint visit to delivered investigation finding. LPA met with new administrator Crystalyn Joseph. LPA explained the purpose of the visit.

Allegation: Staff are not wearing proper PPE at night.

Based on interview with staff. Staff stated that they are trained to use their mask all the time. When facility is on an outbreak the staff wears fit tested N95 until public health clears the facility, then the facility staff will use surgical mask. LPA observed during the visit that all staff were wearing mask.

Continue on LIC9099…
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-20220131141600
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
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Allegation: Staff are sleeping on the NOC shift.

During the course of investigation, LPA attempted to interview clients in care, the staff was interviewed. Based on interview, staff denied knowing or witnessing night shift staff sleeping while on the job.

Allegation: There are no lights in the hallways at night and There are no lights in the bathrooms at night.

Based on LPA’s observation, there is a functional hallways lights and lights at the bathrooms. Staff stated that there was an incident of losing electricity for about 30mins to an hour, however the emergency light turned on right away. Staff denied taking off the night lights or turning it off. Staff stated bathroom lights are off during night but when clients or staff needs to use it, the lights are functional.

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



Exit interview conduct 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