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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455002783
Report Date: 12/06/2022
Date Signed: 12/06/2022 09:37:44 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
05/23/2022 and conducted by Evaluator Donna Gurriere
COMPLAINT CONTROL NUMBER: 25-AS-20220523143823
FACILITY NAME:NICOLET HOME INCFACILITY NUMBER:
455002783
ADMINISTRATOR:OSTERMAN, RUSSELLFACILITY TYPE:
735
ADDRESS:2958 NICOLET LANETELEPHONE:
(530) 262-5002
CITY:REDDINGSTATE: CAZIP CODE:
96001
CAPACITY:6CENSUS: 4DATE:
12/06/2022
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:TYLER WEBBTIME COMPLETED:
09:45 AM
ALLEGATION(S):
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Lack of Supervision.
INVESTIGATION FINDINGS:
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Donna Gurriere, Licensing Program Analyst was in contact and met with Tyler Webb, Administrator. It was alleged that there was a Lack of Supervision of 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: Surgical 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: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022
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-20220523143823
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: NICOLET HOME INC
FACILITY NUMBER: 455002783
VISIT DATE: 12/06/2022
NARRATIVE
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During the investigative process, numerous staff persons were interviewed. Various documents were obtained and reviewed to include medical charting, death certificate, hospital records, photos of pressure injuries, incident reports, Individual Program Plan, Admissions Agreement, and Physician’s Report.

During the interview process it was reported that the resident (Resident 1) was taken to the health center weekly for three weeks prior to being admitted to the hospital for evaluation of pressure injuries. It was stated that the resident was taken to the doctor immediately following pressure injuries being first observed and that the doctor’s orders were being followed. Documentary evidence obtained supports staff statements that the resident was being changed frequently to prevent further advancement of wounds. There was not a preponderance of evidence to show that staff were negligent in seeking medical treatment for the resident’s wounds or following doctor’s orders in wound care.

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: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2