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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455002695
Report Date: 05/20/2021
Date Signed: 05/20/2021 01:15:53 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/06/2021 and conducted by Evaluator Pheej Cheng
COMPLAINT CONTROL NUMBER: 25-AS-20210106155128
FACILITY NAME:PRS - CAPRICORN RETREATFACILITY NUMBER:
455002695
ADMINISTRATOR:HARONG, MENDILLAFACILITY TYPE:
740
ADDRESS:3292 CAPRICORN WAYTELEPHONE:
(530) 605-0922
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY:4CENSUS: 4DATE:
05/20/2021
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Mendilla Harong; AdministratorTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Client are cared for in a rough manner.
INVESTIGATION FINDINGS:
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On 5/20/21 at 11:15 AM, Licensing Program Analyst (LPA) Cheng conducted an unannounced complaint investigation visit to deliver the findings of the above allegation and met with Administrator Mendilla Harong. Prior to initiating the complaint visit, 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; contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks and gloves. Additionally, LPA was screened by Administrator Mendilla Harong.

Continuation on LIC 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kevin Mknelly
LICENSING EVALUATOR NAME: Pheej Cheng
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021
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-20210106155128
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: PRS - CAPRICORN RETREAT
FACILITY NUMBER: 455002695
VISIT DATE: 05/20/2021
NARRATIVE
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Based on statements and documents obtained, LPA determined that there is insufficient information available. Statements from S2 and S4 indicate that they have no knowledge of R1 being handled in a rough manner. Statements from S1 and S5 indicates that they have only heard of R1 being handled in a rough manner but have not visually seen it happen. S3 indicates that although staff are transferring R1 correctly, S3 does not like the way R1 is being handled by staff and confirmed that no injuries have occurred when transferring R1. All statements indicate that R1 appears to be fragile and is aware of R1 needing assistance. S5 stated that there are notes in facility's communication log regarding R1's bruising; however, LPA reviewed the communication log for 2020 and did not observe any notes regarding R1's bruising or being mishandled.

Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Administrator Mendilla Harong had to leave and authorized Administrator Dwight McGuire to sign off on the report.

Exit interview conducted and a copy of report was provided.

SUPERVISORS NAME: Kevin Mknelly
LICENSING EVALUATOR NAME: Pheej Cheng
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021
LIC9099 (FAS) - (06/04)
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