079200856-8-30-2023-15-AS-HHUL-CVPM45-20230915091606

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200856
Report Date: 08/30/2023
Date Signed: 08/30/2023 12:26:29 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
10/25/2022 and conducted by Evaluator Laura Hall

COMPLAINT CONTROL NUMBER: 15-AS-20221025161542

FACILITY NAME:	CYPRESS HOUSE		FACILITY NUMBER:	079200856
ADMINISTRATOR:	SPIECKER, TIFFANY J		FACILITY TYPE:	738
ADDRESS:	24 W. CYPRESS PLACE		TELEPHONE:	(925) 392-0282
CITY:	OAKLEY	STATE: CA	ZIP CODE:	94561
CAPACITY:	4	CENSUS: 3	DATE:	08/30/2023
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Crystalyn Joseph, Administrator		TIME COMPLETED:	12:35 PM

ALLEGATION(S):

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Client was neglected, which led to health deterioration

Facility did not properly safeguard client's property

Facility did not allow visitors

INVESTIGATION FINDINGS:

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On 8/30/2023 at 12:00pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Crystalyn Joseph, Administrator and explained the reason for the visit.

During the course of the investigation, the Department conducted interviews with staff, Reporting Party (RP), obtained and reviewed records.

On the allegation client was neglected, which led to health deterioration, the Department obtained and reviewed medical records from hospital dated 10/05/2020. Review of facility records shows C1 was admitted to facility on 6/10/2020, admitted to the hospital on 9/28/2020 and did not return to the facility. C1’s physicians report

Continued on LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20221025161542

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: 08/30/2023

NARRATIVE

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Continued from LIC9099.

dated 6/8/2020 indicates C1’s weight was 117lbs. C1 was sent to a skilled nursing facility after being discharged from the hospital (unknown date). However, C1’s belongings were not removed from the facility until 10/12/2020. Review of hospital records indicated that C1 is non-verbal and was admitted into the hospital for weakness. Admission weight to the hospital was 117lbs on 9/30/2020, and 123.7 lbs on 10/2/2020. Medical records states that C1’s work up was unremarkable and C1 has a prior history of a diagnosis that accounts for weakness. Medical records further states there was nothing acute and decline appears gradual. It also states the decline may be medication related but that would have to be addressed by the in-house doctor. Review of discharge notes from the emergency room to the hospital indicated C1’s weight was 1/15/2019 130lb, 3/5/2019 130lb, and 2/4/2020 140lb. LPA reviewed multi disciplinary progress notes dated 7-2-2020 to 9-28-2020. Progress notes dated 9/28/2020 indicated C1 was unbalanced, fell, and hit her head. C1 was taken to the hospital but returned that evening. Further review of progress notes dated 9/30/2020 indicated C1 showed signs of weakness and was sent to the hospital and did not return. During the interview with staff all stated that C1 was doing well at the facility. LPA reviewed multi disciplinary progress notes dated 7-2-2020 to 9-28-2020. There was no suspected abuse or neglect noted.

On the allegation, facility did not properly safeguard client’s property, record review indicated the allegation was unsubstantiated on a previous complaint dated 10/26/2021 (15-AS-20201110115353). Further review of Client/resident personal property and valuables (LIC621) indicated facility listed all items that were returned to Client 1 (C1’s) responsible party which was dated 10/23/2020 and included 1 photo album. Interviews with S2 and S4 both stated all items were logged and

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20221025161542

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: 08/30/2023

NARRATIVE

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Continued LIC9099C.

returned to C1’s responsible party.

On the allegation facility did not allow visitors, during interview with the reporting party it was stated that visitation wasn’t allowed at all, including window visits, Zoom, and/or FaceTime. S2, S3, and S4 stated they were working at the facility during the time C1 was at the facility. All staff stated the facility would conduct visit via telephone, FaceTime, Zoom, iPad, or window visits. S3 stated, C1 would receive phone calls and would listen for a little while but would soon walk away. S3 stated a few times C1 had a visit at the window but she could not recall the exact date. S2 stated she recalled C1 receiving telephone calls and a Zoom call once or twice, but never recall anyone coming to visit through the window. S4 recalled during the interview that C1 received telephone calls here and there but did not recall any Zoom or FaceTime calls. LPA observed during record review a letter dated 3/16/2020 where the facility sent health and safety updates to the responsible party’s’ of the clients’ informing that visitors will be screened and visitation will be restricted in the facility, but the facility would allow alternative methods of visiting during the time. LPA also reviewed a memorandum sent to Cypress employees dated 9/30/2020 that the visitor policy had not changed, and no visitors were allowed inside, but window visits were allowed.

Based upon the information obtained and record review during the investigation. The above allegations are 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.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

LIC9099 (FAS) - (06/04)

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