045000603-5-29-2024-59-AS-KHOS-D5YLXR-20240606090911

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045000603
Report Date: 05/29/2024
Date Signed: 05/29/2024 11:19:24 AM

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
03/20/2024 and conducted by Evaluator Donna Gurriere

COMPLAINT CONTROL NUMBER: 59-AS-20240320154545

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: 44	DATE:	05/29/2024
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	SONJA GONZALES		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Locked exterior gate in memory care unit – No waiver is in place.

INVESTIGATION FINDINGS:

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On 03/29/24 Donna Gurriere, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 03/20/24. LPA Gurriere met with Sonya Gonzales, Administrator, and explained the purpose of the visit.

Locked exterior gate in memory care unit – No waiver is in place.

On 03/21/24 Rebecca Knight, LPA observed a lock on the outdoor garden gate in the memory care area. The lock was not to be on the gate, as the administrator had not received a waiver from the licensing agency to have the lock on the gate. The administrator was advised by the LPA to remove the lock. The administrator was informed that because the facility has not submitted a waiver request to the department for a locked gate, the gate cannot be locked. The administrator removed the lock on 03/21/24.

continued

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

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-20240320154545

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: 05/29/2024

NARRATIVE

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Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D.

Appeal Rights were explained and provided to the facility representative listed above and an exit interview was conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20240320154545

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: 05/29/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/29/2024 Section Cited CCR 87209(a)	1 2 3 4 5 6 7	Program Flexibility - The use of alternate concepts, programs, services, procedures, techniques, equipment, space…	1 2 3 4 5 6 7	The administrator has submitted the request to have a waiver in place. Waiver was granted on 04/26/24. No further plan of correction needed.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by observation of the outdoor gate that was locked without a wavier in place. This poses a potential risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Donna Gurriere	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

LIC9099 (FAS) - (06/04)

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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
03/20/2024 and conducted by Evaluator Donna Gurriere

COMPLAINT CONTROL NUMBER: 59-AS-20240320154545

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:	05/29/2024
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	SONJA GONZALES		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Failure to comply with company reporting policies.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

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

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 59-AS-20240320154545

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: 05/29/2024

NARRATIVE

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During the investigation process, It was reported that staff were not aware that the resident (Resident 1) eloped until they found him outside of the facility. Authorities were not contacted because they found the resident before they had time to contact the authorities. Staff were not aware that a resident had eloped from the facility. On 11/28/23 the facility was cited for the resident's elopement.

Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and all of the above findings are Unsubstantiated.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

LIC9099 (FAS) - (06/04)

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