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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002659
Report Date: 10/04/2024
Date Signed: 10/04/2024 01:16:44 PM

Document Has Been Signed on 10/04/2024 01:16 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CAZADERO HOME, INCFACILITY NUMBER:
455002659
ADMINISTRATOR/
DIRECTOR:		OSTERMAN, RUSSELLFACILITY TYPE:
735
ADDRESS:3556 CAZADERO WAYTELEPHONE:
(530) 364-2169
CITY:ANDERSONSTATE: CAZIP CODE:
96007
CAPACITY: 6CENSUS: 4DATE:
10/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Angel Doss AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:30 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
10/04/2024 10:20 AM Licensing Program Analyst (LPA) Sarah Benson arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with Administrator Angel Doss acting for Russell Osterman (cert #6032889735 exp.10-26-26) and explained the purpose of the visit. Administrator certificate is current.

LPA Benson and administrator toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to four (4) resident rooms, common areas, two (2) bathrooms, kitchen, storage areas and back yard. Staff and resident files were reviewed. Medications were also reviewed. Medication is locked in a locked closet. OTC medication was found in a clients room.


The common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. The bathrooms were clean and in good repair. The kitchen was clean and in good repair. Cooking/dining equipment and utensils were present. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food.
The facility was observed to be at a comfortable temperature. First aid kit fully stocked and ready for emergency use. Fire extinguisher fully charged. Smoke detectors are all operational. Hot water temperature measured within required Title 22 regulations of 105 degrees F and 120 degrees F. All employees requiring background checks are cleared. There is a schedule of activities planned for the clients. All required postings are displayed within the facility.

No pools/bodies of water are on the premises. No firearms are on premises. The last disaster drill was conducted and documented on 9-14-24, the facility has been conducting drills every 3 months.

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, a copy of the report, and appeal rights provided to administrator?
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2024
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 10/04/2024 01:16 PM - It Cannot Be Edited


Created By: Sarah Benson On 10/04/2024 at 12:49 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CAZADERO HOME, INC
FACILITY NUMBER: 455002659

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above in one out of four client rooms OTC medication was found guifenesin and two unmarked pills which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2024
Plan of Correction
1
2
3
4
Staff meeting to brain storm for training of entrance to client rooms for assistance of cleaning and monitoring for OTC medication.
Staff medication training.
Staff work with Tony to create weekly room check chart.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Lauren Crocker
LICENSING EVALUATOR NAME:Sarah Benson
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2024


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