525001820-5-24-2022-25-AS-RKNT-CEQRZL-20220524132807

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 525001820
Report Date: 05/24/2022
Date Signed: 05/24/2022 01:28:25 PM

Document Has Been Signed on 05/24/2022 01:28 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 - MARY LANE		FACILITY NUMBER:	525001820
ADMINISTRATOR:	SCHLOTTMAN, LAURIE		FACILITY TYPE:	735
ADDRESS:	200 MARY LN		TELEPHONE:	(530) 527-5362
CITY:	RED BLUFF	STATE: CA	ZIP CODE:	96080
CAPACITY: 6		CENSUS: 4	DATE:	05/24/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Mendee Harrong - administrator		TIME COMPLETED:	02:00 PM

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05/24/2022 1:00 PM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with administrator Mendee Harrong. The purpose of this visit was to conduct a case management investigation. Prior to initiating the 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: N95 Mask, gloves.

Today's meeting concerns an investigation into two incident reports that were received from the facility on 05/19/2022 regarding incidents that occurred at the facility on 05/17/2022. It was reported that on 05/17/20220 Client 1 (C1) had a behavior that escalated into attempting to hit Staff 1 (S1) with a frying pan. S1 locked themselves in the office of the facility hoping to de-escalate the situation. C1 then went into Client 2’s (C2) room and when C1 exited C2’s room C2 had a cut on their forehead and on the top of their head. It is unknown whether C1 did something to cause the injury or C2 did it themselves as they are known to occasionally hit walls with their body. There were no witnesses to what occurred in C2’s room. C1 was inside of C2’s room for about 1 minute. The other staff person was on the phone calling administrator and ensuring the safety of the other clients in the house.

It was learned that S1 was in the office for 2-3 minutes while C1 de-escalated. There was 1 other staff person in the facility at the time of the incident. C1 has not exhibited physical aggression since they moved into the facility one month ago. The contributing factor to triggering this aggression was a telephone call that C1 received while they were participating in an activity.

Continued on LIC809-C

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 - MARY LANE	FACILITY NUMBER: 525001820
	VISIT DATE: 05/24/2022

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In order to prevent this from happening again the facility is going to conduct staff training on dealing with behaviors and monitoring the clients in the aftermath of the behavior.

Staff have been instructed that when C1 is busy doing an activity and receives a telephone call, the caller will be informed that C1 will call them back rather than interrupting C1.

No deficiencies cited. Exit interview conducted and a copy of the report was emailed to administrator Mendee Harrong.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022

LIC809 (FAS) - (06/04)

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