State
of
California-Health and Human Services Agency ADP 7350, Revised 4/09
COMPLAINT FORM
This form
is
intended
to
document complaints
received
Reported
In
Person D
By
Letter
or
E-mail D
By
FAX D
By
Phone
Complainant Name: Address:
City:
Telephone
Number s): E-mail:
Complainant s
Relationship to Provide
C1
-Facility Resident s)
C2-
Facility Staff
C3-
Neighbors
C4-
Relative/Friend
C5-
Public/Gov. Agency
C6
-Anonymous
C7
-Former
Resident
C8
-Former Staff
C9-
Other
***
-Unknown Complaint Number:
10 0500
Department
of
Alcohol and Drug Programs Licensing
and
Certification Division 1700 K Street, Sacramento,
CA
95811 TDD
916)
445-1942,
Fax
916) 322-2658
916)322-2911
D
PR OR TY
Type of Investigation:
DEATH INVESTIGATION
Type
of
Program:
LIC/CERT
Provider License
Number (If
Applicable):
490009CN
Provider Legal Name:
Narconon
of
Northern
California
Facility Name:
Narconon
of
Northern
California
Address s}:
262
Gaffey
Road
City:
Watsonville
Zip:
95076
County:
Santa Cruz Contact
Name:
Jeff
Panelli Telephone
Number: 831) 768-7190 Complainant waives confidentiality of his/her name
and
name of any person named
in
complaint except provider clients.
YES
No
COMPLAINT
RECORDED
BY:
M.
Vasquez
DATE
RECEIVED:
08/12/2010
COMPLETE
FOR
COUNSELOR
MISCONDUCT
COMPLAINTS COUNSELOR NAME CERTIFYING ORGANIZATION
CERTIFICATION
OR EXPIRATION
OR
REGISTRATION
NO. RENEWAL
DATE
COUNSELOR COMPLAINT
(90-DAY)
DUE
DATE:
ALLEGATION
NATURE
OF
COMPLAINT
REGULATION STANDARD)
10561(b)(1)(A)
A·
.::lient
was
enrolled
in the program
on
J
Client died
on
on
I
t
the hospital due
to
<
ASSIGNMENT INFORMATION
4
ASSIGNED FIELD OPERATIONS ANALYST:
Marie Montiero-Gomez
DATE COMPLAINT ASSIGNED:
11/6/2011 (to Alatorre)
ASSIGNED COMPLAINT INVESTIGATOR:
-J-:-B~parks-
\
(
\j~f.::+Qn f~
b
DATE INVESTIGATION WAS INITIATED:
11/6/2011
L
t l
)
1\
1-\
\_C\
Cy 0
INVESTIGATION FINDINGS
ALLEGATION (REGULATION
I
STANDARD) RESULT CLASS ALLEGATION (REGULATION
I
STANDARD) RESULT CLASS 1.10561 (b)(1)(A) SUBSTANTIATED A
6.
10567(a} SUBSTANTIATED B
2.
10561 (b)(1)(A} SUBSTANTIATED A
7.13010(a}/10563
SUBSTANTIATED B
3.
12055/12050/10563 SUBSTANTIATED A 8.10564 (c) (1} SUBSTANTIATED
c
4.
10510 SUBSTANTIATED B
5.10569
SUBSTANTIATED A COUNSELOR MISCONDUCT COMPLAINT FINDINGS ALLEGATION RESULT ORDER
FOLLOW-UP INVESTIGATION
RECOMMENDED CATEGORY OF FOLLOW-UP: FOLLOW-UP VIOLATION (S) RESULTS CLASS FOLLOW-UP VIOLATION (S) RESULTS CLASS
CLOSURE INFORMATION
INVESTIGATION COMPLETED
BY:
i
I \
DATE OF INITIAL SITE VISIT:
11/7/2011 and 11/8/2011
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DATE REVIEW WAS COMPLETED:
12/16/2011
DATE
OF
FINAL REPORT:
2/22/2012
TOTAL FINES ASSESSED:
N/A
DATE CLOSED:
3/30/2012
COMMENTS *Notice
to
complainant
of
findings went
out
pursuant
to
CCR 1
0543(1).
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ANAL
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DATE:
SUPERVISOR ~
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3/30/2012
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Page 2 of 2
State
of
California-Health and Human Services
Agency
ADP 7350, Revised 4/09
COMPLAINT FORM
This form
s
intended
to
document
complaints
received
Reported
0
In Person
0
By
Letter
or
E-mail
D
By
FAX
~ y
Phone
Complainant
Name:
Address:
City:
Teleohone
Number(s): E-mail:
Complainant's
Relationship to Provider:
C1-
Facility Resident(s)
C2
-Facility Staff
C3-
Neighbors
C4-
Relative/Friend
C5
-Public/Gov.
Agency
C6-
Anonymous
C7-
Former Resident
C8
-
Former
Staff
C9-
Other
***
-Unknown
/
;
/
A
(_/{
c
h.-/,
Complaint Number:
10 2570
Department
of
Alcohol and Drug Programs Licensing and Certification Division 1700 K Street, Sacramento,
CA 95811 TDD
(916) 445-1942, Fax (916) 322-2658 (916)
322-2911
~PRIORITY
Type
of
Investigation:
DEATH INVESTIGATION
Type
of
Program:
LIC ONLY
Provider License Number (If Applicable):
090018AN
Provider Legal Name: NARCONON
of
Northern California
Facility Name:
NARCONON-Vista Bay
Address( s
:
1364
Ruth
Haven
Lane
City:
Placerville
Zip: 95667 County: Contact Name:
Daniel
Manson
Telephone Number: (530) 295-5550 Complainant waives confidentiality of his/her name
and
name of any person named
in
complaint except provider clients.
YES
~NO
COMPLAINT
RECORDED
BY:
J.
lto-Orille
DATE
RECEIVED:
February
25, 2011
COMPLETE
FOR
COUNSELOR MISCONDUCT COMPLAINTS COUNSELOR
NAME
CERTIFYING ORGANIZATION CERTIFICATION
OR
EXPIRATION
OR
REGISTRATION
NO.
RENEWAL
DATE
COUNSELOR COMPLAINT (90-DAY)
DUE
DATE:
ALLEGATION
NATURE
OF
COMPLAINT
(REGULATION
STANDARD
Complainant's was
a
client
at the
facility
in
r
Client
10561(b)(1)(A)
went into
the
hospital
in
after being
in
the
hospital
for
about Complainant
feels
that
death
occurrecfoe Ciwse
of
the
treatment at the facility.
Complainant
stated
that is concerned that
the practices
of
the
sauna
treatment.
/
