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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002689
Report Date: 01/03/2022
Date Signed: 01/03/2022 12:39:51 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/03/2022 12:39 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: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: 4DATE:
01/03/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Angel Doss - administratorTIME COMPLETED:
12:45 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
01/03/2021 12:00 PM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year Inspection. The Infection Control domain was not available to this facility on the day of the visit. As a result, LPA Knight selected Annual Continuation for the visit. LPA asked all pertinent infection control questions during the visit. LPA met with administrator Angel Doss and explained the purpose of the visit. Prior to initiating the annual inspection, 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, gloves. Additionally, LPA Knight was screened by Lynn Martin.

LPA Knight and Ms. Doss toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathrooms, kitchen, storage areas, and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA Knight and the administrator completed the infection control inspection and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report was emailed to administrator Angel Doss.
SUPERVISORS NAME: Rayna L Bryson
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2022
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 1