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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002695
Report Date: 07/14/2021
Date Signed: 07/14/2021 02:02:49 PM

Document Has Been Signed on 07/14/2021 02:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
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:
07/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Mendilla Harong (Admin)TIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Konnor Leitzell arrived at the facility unannounced on 7/14/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with Diatria Digall (Staff) and explained the purpose of the visit. At that time, staff member contacted admin and requested her presence to assist with Annual Visit. Prior to initiating the annual inspection, 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 Kenna Compton (Staff) and completed a facility risk assessment. LPA ensured they applied hand sanitizer prior to entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks. Additionally, LPA was screened by Diatria Digall and answers were documented in their visitor screening log. Shortly after, Mendilla Harong (Admin) arrived at facility and LPA explained the purpose for the visit.

LPA and admin toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, three (3) three (3) resident bedrooms, two (2) of two (2) bathrooms, kitchen, garage, laundry room and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and admin completed the infection control domain and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of todays inspection.
Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Konnor Leitzell
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2021
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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