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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002689
Report Date: 01/16/2025
Date Signed: 01/16/2025 09:50:23 AM

Document Has Been Signed on 01/16/2025 09:50 AM - 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:CAPELLA HOME #2 INCFACILITY NUMBER:
455002689
ADMINISTRATOR/
DIRECTOR:		OSTERMAN, RYANFACILITY TYPE:
735
ADDRESS:2561 CAPELLA STTELEPHONE:
(530) 262-5002
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY: 6CENSUS: 3DATE:
01/16/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Angel DossTIME VISIT/
INSPECTION COMPLETED:
10:00 AM
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On 01/16/2025, Licensing Program Analyst (LPA) Ivan Avila arrived unannounced at the facility to conduct a case management visit regarding an incident report the Department received via fax on 01/15/2025. LPA met with Angel Doss, Administrator, on behalf of the facility and explained the purpose of the visit.

LPA Avila collected documents in regard to the incident report. Documents collected include but are not limited to client face sheet, physician report, needs and service plan, conservator ship documents, progress notes, client IPP, and medical documentation.

No deficiencies cited.

An exit interview was conducted and a copy of the report was provided.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Ivan Avila
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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