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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200856
Report Date: 07/21/2023
Date Signed: 07/21/2023 02:18:47 PM

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
07/14/2023 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230714163841
FACILITY NAME:CYPRESS HOUSEFACILITY NUMBER:
079200856
ADMINISTRATOR:SPIECKER, TIFFANY JFACILITY TYPE:
738
ADDRESS:24 W. CYPRESS PLACETELEPHONE:
(925) 392-0282
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY:4CENSUS: 4DATE:
07/21/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Crystalyn Joseph, AdminstratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility staff did not ensure all passageways are free of obstructions.
INVESTIGATION FINDINGS:
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On 07/21/23 around 11:00 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an initial 10-day complaint visit for the above allegation. LPA met with Crystalyn Joseph, Adminstrator (ADM) and explained the reason for the visit.

During the visit LPA interviewed Staff (S1, S2, S3,S4), Witness #3 (W3), reviewed, and obtained documents from Client #1 (C1) file. LPA requested C1's file to include but not limited to the following documents:

continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
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-20230714163841
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: 07/21/2023
NARRATIVE
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 ...continued from LIC9099

LIC500, Client Roster, House Rules, Admission Agreement, Placement Information Sheet, Physician’s Reports, Appraisal/Needs and Services Plan, Recreation Therapy Monthly Reports for 04/2023 to 06/2023, Placement Information Sheet, Crisis Prevention Plan, Medications consent form, Identification and Emergency Contact form, SIR's, most recent START CSCPIP, emails and/or correspondences related to C1's behaviors.

LPA, S1 and S2 toured the facility and C1's bedroom. There were not any blocked passageways leading to C1's bedroom or throughout the facility. Sofas, chairs, tables and bean bags were present in the common areas. Interviews with S1, S2, S3 and S4 revealed that C1 has destructive behaviors that include property damage and moving of the bean bags. S1 stated when C1 feels unsafe, C1 will retreat to C1's bedroom and/or advise S1, S2, S3 or S4 that he/she needs to go outside or go into his/her room. In an effort to not restrain C1 when C1 moves the bean bags and exhibits aggressive behaviors, the staff will remove the barrier of bean bags that C1 has created to feel safe once C1 has calmed down. C1's bedroom has an alternate access via a sliding door and there does not appear to be a fire hazard while C1 is being redirected. The interview with W4 further revealed that RCEB case notes from 07/14/23 stated that S1 and W2 are currently working on alternative behavioral services for C1. C1 was outside, lounging on the patio furniture during the visit. LPA attempted to interview C1, but C1 was not responsive.

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

Exit interview conducted and a copy of this report was provided to ADM.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2