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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200856
Report Date: 09/05/2023
Date Signed: 09/05/2023 12:44:33 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
01/10/2022 and conducted by Evaluator Alona Gomez
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220110094152
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: 3DATE:
09/05/2023
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Crystalyn Joseph, AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident was assaulted by staff while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 9/5/2023 at 10:20 AM, Associate Governmental Program Analyst (AGPA) L. Francisco and Licensing Program Analyst (LPA) A. Gomez arrived unannounced to deliver findings for the above allegation. Upon arrival, AGPA and LPA met with Direct Care Supervisor, Kapiolani Singh and explained the purpose of the visit. AGPA and LPA later met with Administrator, Crystalyn Joseph.

During the course of the investigation, AGPA obtained information, collected documents, and interviewed staff. AGPA was unable to interview clients. It was alleged resident was assaulted by staff while in care. Based on records obtained, a disciplinary suspension notice was issued to S1 on 12/21/21 for utilizing inappropriate physical escort to move a client and S1 was placed on an immediate 2 day suspension. However, LPA discovered during an interview with S2 and S7 that C1 was not dragged out of the laundry, but Crisis Prevention Institute (CPI) was not used appropriately. According to S7, CPI was performed, but due to limited space, client fell on the ground and staff fell on top of client.

REPORT CONTINUES ON 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023
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-20220110094152
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: 09/05/2023
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
On 9/5/23, AGPA and LPA interviewed 4 staff (S3, S4, S5 and S6) and 4 staff denied incident. S4 stated S4 heard S1 escorted C1, but did not hear about C1 being dragged out of the laundry room.

Although the allegation may have happened or are 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 provided to Administrator.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2