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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455002111
Report Date: 11/01/2022
Date Signed: 11/01/2022 11:47:57 AM

Substantiated


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
10/10/2022 and conducted by Evaluator Rebecca Knight
COMPLAINT CONTROL NUMBER: 25-AS-20221010112933
FACILITY NAME:SHASTA COUNTY MENTAL HEALTHFACILITY NUMBER:
455002111
ADMINISTRATOR:GREENE, PAIGEFACILITY TYPE:
772
ADDRESS:2640 BRESLAUER WAYTELEPHONE:
(530) 225-5200
CITY:REDDINGSTATE: CAZIP CODE:
96001
CAPACITY:15CENSUS: DATE:
11/01/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Dwayne Green - Deputy Branch DirectorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility does not have a qualified and currently certified administrator.
INVESTIGATION FINDINGS:
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11/01/2022 11:00 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with Deputy Branch Director Dwayne Green. The purpose of this visit was to deliver complaint investigation results. Prior to initiating the visit, LPA completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Mask, gloves.

During the course of the investigation the Deputy Branch Director, facility administrator, and Adult/Children’s Services Branch Director were interviewed. LPA obtained the following documents to investigate the above allegation: Certificate of completion adult residential facility initial certification issued by Community Training Connection.

Continued on LIC9099
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
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 5
Control Number 25-AS-20221010112933
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: SHASTA COUNTY MENTAL HEALTH
FACILITY NUMBER: 455002111
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2022
Section Cited
CCR
81064(a)
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81064(a) Administrator Qualifications and Duties (a) All social rehabilitation facilities shall have an administrator. This requirement is not met as evidenced by:
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Administrator agrees to complete the required training, and submit all documents required to obtain an administrator certificate. Administrator agrees to provide LPA with timeline to complete all training by 11/15/2022. Administrator agrees to obtain an administrator certificate and submit to LPA Knight once received.
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Based on LPA interviews and document review it was determined that the acting administrator does not have an administrator certificate which poses a potential health and safety risk to residents in care.
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The proof of correction is to be received by LPA Knight by 11/15/2022.
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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: Troy Ordonez
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 25-AS-20221010112933
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: SHASTA COUNTY MENTAL HEALTH
FACILITY NUMBER: 455002111
VISIT DATE: 11/01/2022
NARRATIVE
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Facility does not have a qualified and currently certified administrator - SUBSTANTIATED

It was alleged that the facility does not have a qualified and currently certified administrator.

Adult/Children’s Services Branch Director stated the acting administrator will be taking the test to obtain their administrator certificate on 11/07/2022. LPA has supplied the facility with information to obtain and submit an administrator certificate.

Based on interviews and document review it was determined that the current facility administrator does not hold an administrator certificate.

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. Appeal rights were provided. Exit interview was conducted and the report was emailed to Deputy Branch Duirector Dwayne Greene.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
10/10/2022 and conducted by Evaluator Rebecca Knight
COMPLAINT CONTROL NUMBER: 25-AS-20221010112933

FACILITY NAME:SHASTA COUNTY MENTAL HEALTHFACILITY NUMBER:
455002111
ADMINISTRATOR:GREENE, PAIGEFACILITY TYPE:
772
ADDRESS:2640 BRESLAUER WAYTELEPHONE:
(530) 225-5200
CITY:REDDINGSTATE: CAZIP CODE:
96001
CAPACITY:15CENSUS: DATE:
11/01/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Miguel Rodriguez - Adult/Children’s Services Branch DirectorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff are committing financial fraud - UNSUBSTANTIATED
INVESTIGATION FINDINGS:
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11/01/2022 11:00 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with Deputy Branch Director Dwayne Green. The purpose of this visit was to deliver complaint investigation results. Prior to initiating the visit, LPA completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Mask, gloves.

During the course of the investigation the Deputy Branch Director, facility administrator, and Adult/Children’s Services Branch Director were interviewed.

Continued on LIC9099
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 25-AS-20221010112933
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: SHASTA COUNTY MENTAL HEALTH
FACILITY NUMBER: 455002111
VISIT DATE: 11/01/2022
NARRATIVE
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Staff are committing financial fraud - UNSUBSTANTIATED

It was alleged that Staff are committing financial fraud.

This complaint was submitted anonymously therefore LPA could not obtain more details about this allegation.

It was determined that the allegation is too vague to investigate without further details from complainant. 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.

An exit interview was conducted. A copy of the report was emailed to facility administrator Dwayne Greene. No deficiency was cited.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5