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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002555
Report Date: 08/20/2021
Date Signed: 08/20/2021 01:46:29 PM

Document Has Been Signed on 08/20/2021 01:46 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:OSTERMAN CERRO, INC.FACILITY NUMBER:
455002555
ADMINISTRATOR:OSTERMAN, RYANFACILITY TYPE:
735
ADDRESS:4582 CERRO LANETELEPHONE:
(530) 949-8756
CITY:REDDINGSTATE: CAZIP CODE:
96001
CAPACITY: 6CENSUS: DATE:
08/20/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Administrator Angel DossTIME COMPLETED:
03:31 PM
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
Licensing Program Analyst (LPA) Valencia arrived at the facility unannounced on 08/20/2021 to conduct a case management visit, LPA met with administrator Angel Doss and explained the purpose of the visit. Prior to initiating the case management, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask. Additionally, LPA was screened by facility staff upon entry.

LPA received a phone call regrading an incident that happened between a staff member and client from facility from Administrator (Admin) Paula Davis

Admin Paula Reported the following; On 11/06/2020 staff member (S2) was informed that client (C1) having behavior issue and staff member (S1) stated he had to take him down. S1 stated that C1 was physically attacking him and had no other choice. S1 reported that he took C1 down and sat on his chest holding his arms above his head and poked his finger into C1's chest yelling and cussing at him.

Paula reports that Administrator Angel Doss spoke to S1,who admitted to her that he did in fact yell at C1 and push him away from him, but not holding him down. C1 was checked for injuries, which he had none, but we decided to terminate S1. Administrator Angel Doss faxed in an incident report and supporting documents.
The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted and appeal rights provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Misty Valencia
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 08/20/2021 01:46 PM - It Cannot Be Edited


Created By: Misty Valencia On 08/20/2021 at 01:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: OSTERMAN CERRO, INC.
FACILITY NUMBER: 455002555

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/20/2021
Section Cited
CCR
82072(a)(1)

1
2
3
4
5
6
7
Each client shall have personal rights which include, but are not limited to, the following: To be accorded dignity in his/her personal relationships with staff and other persons This requirement was not met based on
1
2
3
4
5
6
7
This is corrected during visit. The staff member was terminated after an internal investigation done by the Administrator, and the incident was discussed with the remaining staff.
8
9
10
11
12
13
14
interviews and record reviews; S1 inappropriately restrained C1 poking C1’s chest, yelling and cussing at C1. The client was not injured. This poses an immediate threat to the client.
8
9
10
11
12
13
14
Licensee agrees that they will develop a policy to ensure that employees are screened as thoroughly as possible prior to employment.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Maribeth Senty
LICENSING EVALUATOR NAME:Misty Valencia
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2021


LIC809 (FAS) - (06/04)
Page: 2 of 2