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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455002689
Report Date: 09/26/2022
Date Signed: 09/26/2022 10:55:25 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/01/2022 and conducted by Evaluator Donna Gurriere
COMPLAINT CONTROL NUMBER: 25-AS-20220601123145
FACILITY NAME:CAPELLA HOME #2 INCFACILITY NUMBER:
455002689
ADMINISTRATOR:OSTERMAN, RYANFACILITY TYPE:
735
ADDRESS:2561 CAPELLA STTELEPHONE:
(530) 262-5002
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY:6CENSUS: DATE:
09/26/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:ANGEL DOSSTIME COMPLETED:
11:20 AM
ALLEGATION(S):
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Lack of supervision - Resident suffered broken ribs.
INVESTIGATION FINDINGS:
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Donna Gurriere, Licensing Program Analyst was in contact and met with Angel Doss, Administrator. It was reported that there was a Lack of Supervision - Resident suffered broken ribs.


LPA Gurriere completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID 19 infection to affirm no COVID-19 related symptoms. The administrator/staff person was contacted to complete a facility risk assessment. LPA Gurriere ensured that hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. Additionally, LPA Gurriere was screened by a staff person upon entering the facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022
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 25-AS-20220601123145
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: CAPELLA HOME #2 INC
FACILITY NUMBER: 455002689
VISIT DATE: 09/26/2022
NARRATIVE
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Lack of supervision- Resident suffered broken ribs.
During the investigation, numerous persons were interviewed, and several documents were obtained. Documents included X-rays, Physician Medical Records, lab results, Medication Records, Physician’s Report, Individual Program Plan, Functional Capability Assessment, Facility Notes, and Admission Agreement.

During the interview process, it was reported that a resident (Resident 1) sustained broken ribs. It was unclear when and how the injury occurred, as there were no direct witnesses. It was stated that staff denied seeing any signs of bruising or anything to indicate that the resident was injured. Resident is nonverbal and could not communicate that she suffered an injury; the resident did not have a specific gesture to express pain. It was indicated that it may have been possible that the resident fell out of her wheelchair and suffered broken ribs, which was undetected by staff.

Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2