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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045000603
Report Date: 11/01/2023
Date Signed: 11/01/2023 01:04:23 PM


Document Has Been Signed on 11/01/2023 01:04 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 OROVILLEFACILITY NUMBER:
045000603
ADMINISTRATOR:GONZALES, SONYAFACILITY TYPE:
740
ADDRESS:400 EXECUTIVE PARKWAYTELEPHONE:
(530) 534-8160
CITY:OROVILLESTATE: CAZIP CODE:
95966
CAPACITY:88CENSUS: 32DATE:
11/01/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Sonya Gonzales.- Executive DirectorTIME COMPLETED:
01:15 PM
NARRATIVE
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11/01/2023 11:45 PM 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 10/21/2023 and was reported to licensing on 10/24/2023.

It was reported that on 10/21/2023 Butte County Sheriff department arrived at the facility with Resident 1 (R1). Sheriff advised they found R1 on the sidewalk near Oroville Hospital. It was reported that the landscapers left the exterior gate to the memory care unit unsecured and R1 exited the facility through the gate. R1 denied injury and had no visible Injury. Family did not want R1 transported to the ER. Facility assessed R1, found no visible injuriies and determined that R1. was at baseline.

During the course of the investigation, it was learned that the gardener had come into the gate via a combination lock and let themselves out after they were finished with their duties and did not secure the gate. Resident 1 (R1) left through the unsecured gate and was returned by sheriff to the facility. Staff were unaware that R1 had eloped.

During today's visit LPA observed a keyed padlock and audible chime have been added to the memory care gate. LPA advised Executive Director that the facility must obtain a waiver for the locked gate. Executive Director was unsure as to whether the facility already has a waiver. LPA will follow up on the locked gate with administrator. Executive Director has made arrangements for the gardener to check in on arrival, staff will open the gate. The gardener will notify staff when finiished and staff will let them out and secure the gate.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the 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 provided to Executive Director Sonya Gonzales.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 11/01/2023 01:04 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/15/2023
Section Cited
CCR
87705(j)

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87705(j) Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by:
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The licensee has placed a chime on the memory care gate that will chime if the gate opens. The licensee has made arrangements for the gardener to check in on arrival, staff will open the gate. The gardnener will notify staff when fininshed and staff will let them out and secure the gate.
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Based on LPA interviews and observation the gate to the memory care patio was left unsecured by the gardener and 1 resident eloped down the street and was returned to the facility by law enforcement 20 minutes after eloping. Staff were unaware that the resident had eloped. This poses an immediate health and safety risk to residents in care.
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Plan of correction has been completed based on LPA visit.

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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.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2