045000603-9-28-2023-59-AS-RKNT-CW4QL5-20230928121521

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 045000603
Report Date: 09/28/2023
Date Signed: 09/28/2023 12:15:36 PM

Document Has Been Signed on 09/28/2023 12:15 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	PRESTIGE ASSISTED LIVING AT OROVILLE		FACILITY NUMBER:	045000603
ADMINISTRATOR:	GONZALES, SONYA		FACILITY TYPE:	740
ADDRESS:	400 EXECUTIVE PARKWAY		TELEPHONE:	(530) 534-8160
CITY:	OROVILLE	STATE: CA	ZIP CODE:	95966
CAPACITY:	88	CENSUS: 32	DATE:	09/28/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Sonya Gonzales.-Executive Director		TIME COMPLETED:	12:30 PM

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09/28/2023 11:30 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Executive Director Sonya Gonzales. Today’s visit is regarding an incident that occurred on 09/06/2023 and was reported to licensing on 09/12/2023. This is a follow up visit.

It was reported that on 09/06/2023 at 1:30 PM Staff checked on Resident 1 (R1) who was found standing naked and slurring their words. R1 stated they were in pain and had taken some medication “from a friend.” 911 was called and R1 was transported to the local emergency room for evaluation. R1’s family and physician were notified. R1 was admitted to hospital with a diagnosis of toxic metabolic encephalopathy.

During the course of the investigation, it was learned that R1 is independent with all ADL’s but the facility manages R1’s medication for them. Even though R1’s LIC602 Physician’s Report dated 03/30/2023 reflects that R1 is able to administer and store their own medication they chose to have the facility manage their medication for them. Without the facility’s knowledge R1 ordered a supplement online that is marketed to support mood, mental clarity, cognitive performance and a CBC supplement that does not contain THC. These supplements are not included in R1’s Medication Administration Record (MAR) for the month of September 2023. The facility administrator located these supplements in R1’s room and notified the hospital. It is unknown how long R1 had been ingesting the supplements. R1 was hospitalized a second time on 09/19/2023. During this hospital stay on the advice of a hospital psychiatrist R1 was subsequently admitted to behavioral health to be treated for depression. Facility staff are going to Behavioral Health to assess R1 for possible return to facility. Administrator has recommended Home Health Behavioral nurse follow-up at the facility when R1 returns.

Continued on LIC809-C

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PRESTIGE ASSISTED LIVING AT OROVILLE	FACILITY NUMBER: 045000603
	VISIT DATE: 09/28/2023

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In order to prevent this from happening again the facility will update R1’s care plan so the plan addresses R1’s sudden change in condition. Facility will develop a harm reduction safety plan for R1 that includes the dangers of ingesting supplements without the advice of their physician, and talk to R1’s doctor about what they recommend for R1’s treatment moving forward. The facility will also obtain an updated LIC602 Physician’s Report to include R1’s inability to manage their own medications.

No deficiencies were cited as a result of today’s visit. Exit interview conducted and a copy of the report was provided to Sonya Gonzales.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC809 (FAS) - (06/04)

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