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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 10:53:29 AM

Substantiated


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: 3DATE:
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 - Staff failed to seek timely medical care for a resident.
INVESTIGATION FINDINGS:
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Donna Gurriere, Licensing Program Analyst (LPA) was in contact and met with Angel Doss, Administrator. It was alleged that there was a Lack of supervision - Staff failed to seek timely medical care for a resident.

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.
Substantiated
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 3
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 - Staff failed to seek timely medical care for a resident.
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 staff failed to seek timely medical care for a Resident (Resident 1). It was stated that the resident had lost a substantial amount of weight with no answers. On 04/04/22 and 04/28/22 the resident’s physician ordered lab work. The physician indicated the importance of getting the lab work completed for the resident and a nurse spoke personally with the administrator advising the need to get the lab work completed. The administrator reported that staff did attempt to get the lab work completed; however, stated that the resident was uncooperative. There were no records to corroborate the failed attempts of getting the lab work done. The resident’s lab tests and X-rays were not completed until 05/27/22, which was when it was discovered that the resident suffered broken ribs. It took the administrator nearly six weeks to get the tests completed.

Based on observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be Substantiated. California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D.

Appeal Rights were explained and provided to the facility representative listed above and an exit interview was conducted. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.

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: 3 of 3
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/27/2022
Section Cited
CCR
80078(a)
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Responsibility for Providing Care and Supervision - The licensee shall provide care and supervision as necessary to meet the client's needs.
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The licensee agrees to provide training to the staff in regards to the importance of following up on a physician's order, which was getting lab results in a timely manner.
A copy of the training and a list of the staff persons that were trained shall be sent to the licensing agency by 09/27/22.
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The administrator did not ensure that this was met as evidenced by interviews and documents reviewed in that the administrator did not seek medical care in a timely manner for a resident. This poses an immediate health and safety risk to residents in care.
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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: Anthony Perez
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

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

DATE: 09/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3