455002555-11-20-2023-59-AS-KHOS-CY3RZS-20231130122824

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 455002555
Report Date: 11/20/2023
Date Signed: 11/20/2023 12:02:40 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/05/2023 and conducted by Evaluator Jaynae Boyles

COMPLAINT CONTROL NUMBER: 59-AS-20230705154914

FACILITY NAME:	OSTERMAN CERRO, INC.		FACILITY NUMBER:	455002555
ADMINISTRATOR:	OSTERMAN, RYAN		FACILITY TYPE:	735
ADDRESS:	4582 CERRO LANE		TELEPHONE:	(530) 949-8756
CITY:	REDDING	STATE: CA	ZIP CODE:	96001
CAPACITY:	6	CENSUS: 5	DATE:	11/20/2023
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Program Manager- Angel Doss		TIME COMPLETED:	12:10 PM

ALLEGATION(S):

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Neglect/Lack of Care and Supervision resulting in resident sustaining an injury.

INVESTIGATION FINDINGS:

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11/20/2023 Licensing Program Analyst (LPA) Jaynae Boyles made an unannounced visit to the facility and met with Program Manager. The purpose of this visit was to deliver the results of a complaint investigation.
On 07/03/2023, Resident (R1) was seen at the Emergency Department (ED) following bruising and swelling being observed on his penis by his day program staff. ED staff were interviewed and stated the injury appeared to have been caused by blunt force trauma, as if his penis had been hit or “smashed.”

During the course of the investigation the administrator, staff, witnesses, and Primary Care Provider were interviewed. LPA reviewed the following documents: Staff schedule, Facility file review including, admissions agreement, Physician report, Medical and Dental Record, Individual Service Plan, Semi Annual Summary of services, General Event Record, Shasta Regional Medical Center Medical Records.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

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 59-AS-20230705154914

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: OSTERMAN CERRO, INC.	FACILITY NUMBER: 455002555
	VISIT DATE: 11/20/2023

NARRATIVE

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During the interview process, day program and facility staff were interviewed. It was determined that a facility staff, admitted to observing the bruising while showering R1 on 07/03/2023 but did not report the bruising to anyone. Day program and facility staff all consistently provided statements that the bruising and swelling resolved within a few days.

The second incident of bruising occurred on 07/10/2023. A second staff stated that he toileted R1 on 07/10/2023 at about 1400 hours and when R1 stood up, R1 had bruising on his penis. The staff person attested that there was no bruising prior to R1 sitting down and that R1 had been sat down in a way that ensured R1 penis was not constricted. Staff suspected that R1 scooted himself forward while he was sitting on the toilet. R1 was taken to the ED, as well as his primary care provider, who was interviewed and stated that she had never had cause for concern regarding R1 care and that the explanation R1 caregivers provided had been plausible for the cause of R1’s injury.

Multiple staff were interviewed and provided consistent statements that R1 had a propensity to “plop” down and scoot himself on the toilet seat while toileting. Facility administrators promptly sought medical treatment following both injuries and installed a different style toilet seat after witnessing the second injury occur while R1 was toileting. All staff stated there have been no further injuries or issues since the toilet seat was changed.

This agency has investigated the complaint alleging Neglect/Lack of Care and Supervision resulting in an injury. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED.

An exit interview was conducted. A copy of the report was provided to Program Manager Angel Doss.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

LIC9099 (FAS) - (06/04)

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