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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002758
Report Date: 06/16/2023
Date Signed: 07/05/2023 08:27:37 AM

Document Has Been Signed on 07/05/2023 08:27 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:OSTERMANS FACILITY # 1 INC.FACILITY NUMBER:
455002758
ADMINISTRATOR:OSTERMAN, RUSSELLFACILITY TYPE:
735
ADDRESS:1751 DAKOTA WAYTELEPHONE:
(530) 262-5002
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY: 6CENSUS: 4DATE:
06/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:07 PM
MET WITH:Angelia Doss AdministratorTIME COMPLETED:
02:15 PM
NARRATIVE
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06/16/2023 12:00 PM Licensing Program Analyst (LPA) Sarah Benson arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with Angelia Doss Administrator (cert #6058906735 exp.03-07-25) and explained the purpose of the visit.

LPA Benson and the 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. In the areas toured no immediate health, safety, or personal rights violation was observed and one technical advisor was cited. Staff and resident files were reviewed. Medications were also reviewed.



Common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Medication is locked in a locked closet.

Administrator certificate is current. First aid kit fully stocked and ready for emergency use. Fire extinguisher fully charged. Smoke detectors are all operational and last serviced ???. Hot water temperature measured within required Title and last serviced 03-23. All required postings are displayed within facility.

No pools/bodies of water are on premises. No firearms are on premises. Last disaster drill was conducted and documented on 05-06-23, the facility has been conducting drills every month.

The following deficiencies were observed (See LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Deficiencies were cleared at time of annual.



Exit interview conducted and copy of report was provided to Angelia Doss Administrator.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2023
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 3
Document Has Been Signed on 07/05/2023 08:27 AM - It Cannot Be Edited


Created By: Sarah Benson On 06/21/2023 at 11:23 AM
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: OSTERMANS FACILITY # 1 INC.
FACILITY NUMBER: 455002758

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80076(a)(15)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (15) Pesticides and other similar toxic substances shall not be stored in food storerooms, kitchen areas, food preparation areas, or areas where kitchen equipment or utensils are stored.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2023
Plan of Correction
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Cleared during visit.
Staff will store Pesticides and other similar toxic substances in locked areas.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 06/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/05/2023 08:27 AM - It Cannot Be Edited


Created By: Sarah Benson On 06/21/2023 at 11:24 AM
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: OSTERMANS FACILITY # 1 INC.
FACILITY NUMBER: 455002758

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80076(a)(15)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (a) In facilities providing meals to clients, the following shall apply: (15) Pesticides and other similar toxic substances shall not be stored in food storerooms, kitchen areas, food preparation areas, or areas where kitchen equipment or utensils are stored.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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2
3
4
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: 06/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2023


LIC809 (FAS) - (06/04)
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