045000603-11-28-2023-59-AS-KHOS-CY3SK7-20231130125615

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045000603
Report Date: 11/28/2023
Date Signed: 11/28/2023 12:10:48 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/27/2023 and conducted by Evaluator Rebecca Knight

COMPLAINT CONTROL NUMBER: 59-AS-20231127101957

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:	DATE:	11/28/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Sonya Gonzales - Executive Director		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Staff were not aware that a resident had eloped from the facility. – SUBSTANTIATED

INVESTIGATION FINDINGS:

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11/28/2023 11:00 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with Executive Director Sonya Gonzalez. The purpose of this visit was to open a complaint investigation.

LPA interviewed the Executive Director, Expressions Director and 2 staff at the facility and 3 staff by telephone during the visit.

Continued on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20231127101957

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/28/2023

NARRATIVE

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Staff were not aware that a resident had eloped from the facility. – SUBSTANTIATED.

It was reported that Resident 1 (R1) eloped from the facility's memory care unit. Staff were not aware that R1 was missing from the facility until R1’s family came to the facility to visit R1 and R1 could not be located at the facility by staff. R1 was found a substantial distance from the facility and was returned to the facility by a community member.

Staff interviews revealed that staff were made aware that R1 had eloped when R1's family came to the facility to visit R1 and R1 was not in the memory care unit. There were two PCAs on duty in the memory care unit and one Med Tech was floating between the assisted living side of the facility and the memory care unit. No one witnessed R1 eloping. Some staff thought that R1 could have eloped through the garden gate but the gate was latched from the inside when staff checked after it was discovered that R1 had eloped. Some staff thought that R1 may have eloped through the front doors of the memory care unit. Staff did not know how R1 had eloped from the facility.

Executive Director (ED) stated the last time R1 was seen was at about 2:00 PM and R1 was brought back to the facility at around 3:30 PM. ED stated that the surveillance cameras had malfunctioned during the time that R1 had eloped and therefore there was no surveillance footage for LPA to review to determine whether R1 had eloped through the front doors of the memory care unit.

It was determined that R1 eloped from the facility without staff being aware and was out of the facility for about 1.5 hours, unknown to staff. It is unknown how R1 eloped from the facility, there were no witnesses. This allegation is substantiated.

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 Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20231127101957

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/28/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/12/2023 Section Cited CCR 87705	1 2 3 4 5 6 7	87705(a)(c)(4) Care of Persons with Dementia (a) This section applies to licensees who accept or retain residents diagnosed by a physician to have dementia. Mild cognitive impairment, as defined in Section 87101(m), is not considered to be dementia. (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.	1 2 3 4 5 6 7	Licensee agrees to increase staffing levels in the memory care unit to meet resident’s needs and to provide adequate supervision to residents in care. Licensee will send an updated LIC 500 showing that staffing is adequate to meet residents’ needs in the memory care unit.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on staff interviews, the licensee failed to ensure that there were sufficient staff present to provide supervision to residents to ensure that no residents eloped from the facility. As a result, R1 eloped from the facility and was found a substantial distance from the facility by a community member and was returned to the facility. Staff were not aware that R1 had eloped until R1’s family came to visit them and R1 was not present at the facility. This poses an immediate health, welfare and safety hazard to residents in care.	8 9 10 11 12 13 14	New LIC 500 to be submitted to LPA as proof of correction by 12/12/2023.
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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 Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

LIC9099 (FAS) - (06/04)

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