045000603-4-23-2024-59-AS-KHOS-D64KZ6-20240610082012

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045000603
Report Date: 04/23/2024
Date Signed: 04/23/2024 09:59:51 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
03/29/2024 and conducted by Evaluator Donna Gurriere

COMPLAINT CONTROL NUMBER: 59-AS-20240329084743

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: 45	DATE:	04/23/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	SONYA GONZALES		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Medication Administration.

INVESTIGATION FINDINGS:

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On 04/23/24 Donna Gurriere, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 03/29/24. LPA Gurriere met with Sonya Gonzales, Administrator, and explained the purpose of the visit.

Medication Administration.

During the interview process, documents were obtained to include the Physician’s Report, Admission Agreement, employee names and telephone numbers, resident names, and resident power of attorney names and telephone numbers.

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: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

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-20240329084743

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: 04/23/2024

NARRATIVE

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During the investigation process, a video feed was observed by LPA Gurriere of a staff person entering a resident’s (Resident 1) room and petting the resident’s cat. The staff person then took out a treat from the treat container and gave it to the cat. After petting and feeding the cat, the staff person gave the resident her medications, which included eye drops and a sublingual on the tongue pain medication. The staff person was not wearing gloves when administering the medication, nor had the staff person washed her hands after touching and feeding the cat. The staff person did not practice infection control hand hygiene medication administration.

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: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20240329084743

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: 04/23/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/24/2024 Section Cited CCR 87470(a)(1)(B)(3)	1 2 3 4 5 6 7	Infection Control Requirements - A licensee shall ensure that infection control practices are maintained as follows: All staff and volunteers shall perform hand hygiene. Hand hygiene shall be conducted before and after assisting with medications.	1 2 3 4 5 6 7	The administrator shall provide training to all staff regarding infection control and hand hygiene when administering medication. The administrator shall submit to the licensing agency a list of staff persons trained and the training material.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on video feed observed by LPA Gurriere, the licensee did not ensure that infection control and hand hygiene were used when administering medication. This poses an immediate 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: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

LIC9099 (FAS) - (06/04)

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