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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455002659
Report Date: 07/16/2024
Date Signed: 07/16/2024 01:34:55 PM

Substantiated


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
03/18/2024 and conducted by Evaluator Sarah Benson
COMPLAINT CONTROL NUMBER: 59-AS-20240318135737
FACILITY NAME:CAZADERO HOME, INCFACILITY NUMBER:
455002659
ADMINISTRATOR:OSTERMAN, RUSSELLFACILITY TYPE:
735
ADDRESS:3556 CAZADERO WAYTELEPHONE:
(530) 262-5002
CITY:ANDERSONSTATE: CAZIP CODE:
96007
CAPACITY:6CENSUS: 4DATE:
07/16/2024
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Angel Doss AdministratorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff calling resident names.
INVESTIGATION FINDINGS:
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 On 7-16-24 at 1:10PM Sarah Benson, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 3-18-24. LPA Benson met with Angel Doss Administrator, and explained the purpose of the visit.

Staff calling resident names.

During the interview process, three staff persons and one resident were interviewed. The following documents were received and reviewed: Client and staff list with telephone numbers, employee work schedule, and observation logs.

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
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 5
Control Number 59-AS-20240318135737
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: CAZADERO HOME, INC
FACILITY NUMBER: 455002659
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/16/2024
Section Cited
CCR
80072(a)(1)
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Personal Rights
(a) each client shall have personal rights which include, but are not limited to, the following:(1)To be accorded dignity in his/her personal relationships with staff and other persons...This requirement was not met as evidenced by:
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The administrator agrees to submit to the licensing agency a statement of how this type of deficiency will be avoided in the future.
The administrator will notify LPA when complete.
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During staff and cliient interviews and record review it was discovered staff called the client names.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 59-AS-20240318135737
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: CAZADERO HOME, INC
FACILITY NUMBER: 455002659
VISIT DATE: 07/16/2024
NARRATIVE
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 During the investigation process, staff and clients interviewed, indicated that a staff person called a client names. Administrator stated the facility did have a staff member employed for just over a month. Administrator reported as soon as it was reported the staff person was calling clients names, the staff person was fired. During the client interview it was reported that staff called the client names.

Based on investigation, observations, record review(s), interviews which were conducted and recorded, we have found that the complaint is Substantiated.


Based on investigation observations, interviews which were conducted and recorded and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Appeal rights were provided and exit interview conducted.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5
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
03/18/2024 and conducted by Evaluator Sarah Benson
COMPLAINT CONTROL NUMBER: 59-AS-20240318135737

FACILITY NAME:CAZADERO HOME, INCFACILITY NUMBER:
455002659
ADMINISTRATOR:OSTERMAN, RUSSELLFACILITY TYPE:
735
ADDRESS:3556 CAZADERO WAYTELEPHONE:
(530) 262-5002
CITY:ANDERSONSTATE: CAZIP CODE:
96007
CAPACITY:6CENSUS: 4DATE:
07/16/2024
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Angel Doss AdministratorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff and another resident stealing from resident.
INVESTIGATION FINDINGS:
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During the interview process, three staff persons and one resident were interviewed. The following documents were received and reviewed: Client and staff list with telephone numbers, employee work schedule and observation logs.




Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 59-AS-20240318135737
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: CAZADERO HOME, INC
FACILITY NUMBER: 455002659
VISIT DATE: 07/16/2024
NARRATIVE
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During the investigation process, staff interviewed, indicated that clients miss place their things. Staff members find the missing items when searching the clients’ personal belongings. Staff stated one resident stole fifty dollars from me when I put my information in his phone so he could pay for a door dash gift card. Staff reported there have been allegations of a resident stealing food and cigarettes. A staff reported the same resident was caught on camera stealing a dollar or something from another resident’s room when I was in the bathroom; however the staff person could not remember exactly. Overall based on the interviews it could not be proven that a staff person or a resident stole from others. Unsubstantiated.

Based on the interviews conducted the allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5