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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002695
Report Date: 06/22/2022
Date Signed: 06/22/2022 09:57:34 AM

Document Has Been Signed on 06/22/2022 09:57 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
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: 3DATE:
06/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Latisha Russell, Direct Care Staff (DCS)TIME COMPLETED:
10:30 AM
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On 06/22/2022 Licensing Program Analysts (LPA) Misty Valencia arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with Latisha Russell Direct Care Staff (DCS) and explained the purpose of the 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 DCS 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: Surgical Mask. Additional LPA was screen at the back door before entering the facility.

LPA Valencia and Ms Russell toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to common areas, three (3) resident bedrooms, two (2) bathrooms, kitchen, storage areas, and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA Valencia and Ms. Russell 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. Copy of the report emailed to Ms. Horang
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Misty Valencia
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2022
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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