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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200856
Report Date: 12/21/2023
Date Signed: 12/21/2023 05:26:17 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
12/13/2023 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20231213103033
FACILITY NAME:CYPRESS HOUSEFACILITY NUMBER:
079200856
ADMINISTRATOR:JOSEPH, CRYSTALYNFACILITY TYPE:
738
ADDRESS:24 W. CYPRESS PLACETELEPHONE:
(925) 392-0282
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY:4CENSUS: 2DATE:
12/21/2023
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Crystalyn Joseph/AdministratorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff hit a resident in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At 12:20 p.m. on this day, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct investigation of the above allegation. LPA met with Direct Care Supervisor Kapiolani 'Lani' Singh, and informed the reason for visit. Crystalyn Joseph, administrator, arrived at around 1:00 p.m.

It was alleged that staff (S1 and S2) use broom or other objects to scare and/or hit the resident when resident is having behavior.

During the course of investigation, LPA obtained copies of staff schedule and contact information and copies of resident's Individual Behavior Support Plan and Target Behaviors. LPA also conducted interviews.

.....continued on 9099C
.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
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-20231213103033
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: 12/21/2023
NARRATIVE
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S1, S2, S3, S5 all denied using broom or other objects to hit residents when residents are having behaviors which were confirmed with Administrator, S4 and S6. Administrator stated she never receive any complaint about staff using objects to hit or scare residents. All staff interviewed stated R3 has behavior of grabbing and throwing objects including broom to the staff but not the staff using broom to scare R3. These was confirmed by LPA upon review of R3's documents.

Based on interviews conducted and review of documents, and LPA unable to obtain information from residents, R1 and R2, the allegation is unsubstantiated. An unsubstantiated findings means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

There is no deficiency noted.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2