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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455002783
Report Date: 10/05/2023
Date Signed: 10/05/2023 02:24:20 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/01/2023 and conducted by Evaluator Jaynae Boyles
COMPLAINT CONTROL NUMBER: 59-AS-20230501105533
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:
10/05/2023
UNANNOUNCEDTIME BEGAN:
01:34 PM
MET WITH:Licensee- Ryan Osterman TIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Personal Rights Violation- Staff failed to seek timely medical treatment
INVESTIGATION FINDINGS:
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On 10/5/2023 Licensing Program Analysst (LPAs) Jaynae Boyles and Sarah Benson, made an unannounced visit to the facility and met with Administrator Ryan Osterman. The purpose of this visit was to deliver the results of a complaint investigation.
During the investigation the Administrator, staff, and clients were interviewed. The Department received the following documents: Service Request, Facility File review documents, Email from Deputy Coroner, Dignity Health Mercy Medical/Ambulance Records, Certified Death Certificate, and Staff Schedule.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
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 59-AS-20230501105533
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: NICOLET HOME INC
FACILITY NUMBER: 455002783
VISIT DATE: 10/05/2023
NARRATIVE
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Administrator was interviewed and stated that she was notified the morning of 04/29/2023 that an assistant administrator was enroute to the facility to transport the resident (R1) to the hospital because it was reported that R1 was “not acting right.” Staff told Administrator that R1 had “thrown up a little,” was “unusually bloated,” running a fever, and not wanting to eat. Administrator confirmed that she instructed staff not to take the resident to the hospital and to provide a laxative first, as was the resident constipation protocol. Administrator confirmed that she did not respond to the facility in person to assess R1, but stated that staff, “did not tell me anything that seemed like he needed to go.” However, Administrator admitted that it was not common for R1 to throw up or not want to eat. The administrator waited approximately 24 hours before seeking medical treatment for the resident.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D.

As a result of the resident’s death, the violation warrants an immediate civil penalty in the amount of $500, which is being issued. At this time, the issuance of an additional civil penalty is still being determined and the Administrator has been informed that an additional civil penalty may be assessed, at a later date, based on Health and Safety Code §1569.49.

Exit interview held, copy of Appeal Rights provided.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20230501105533
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: NICOLET HOME INC
FACILITY NUMBER: 455002783
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/05/2023
Section Cited
CCR
80065(a)
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80065(a) Personnel Requirements
Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.
The requirement is not met as evidence by:
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The proof of correction is to be received by LPA Boyles by 10/6/2023. Create a policy and procedure for staff to reference when it is noticed that there is a change of condition in a resident. Provide training to all staff for the new policywith two weeks.
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Based on observation, interview and record review, the Administrator did not provide adequate care and supervision as staff did not seek out medical assistance timely, which poses an immediate Health, Safety, Personal Rights risk to persons 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: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3