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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045000603
Report Date: 06/18/2024
Date Signed: 06/18/2024 12:54:08 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
04/22/2024 and conducted by Evaluator Rebecca Knight
COMPLAINT CONTROL NUMBER: 59-AS-20240422163742
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: 38DATE:
06/18/2024
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Sonya GonzalezTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Licensee did not safeguard the confidentiality of residents' records – SUBSTANTIATED
INVESTIGATION FINDINGS:
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06/18/2024 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 deliver the results of a complaint investigation.

During the course of the investigation LPA interviewed the Executive Director. LPA reviewed the following documents: Photographs.

Continued on LIC9099-C

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 59-AS-20240422163742
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: 06/18/2024
NARRATIVE
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Licensee did not safeguard the confidentiality of residents' records – SUBSTANTIATED

It was alleged that a bag of confidential resident records was left in the common area / activity room.

LPA reviewed 16 photographs that were submitted by the complainant. The photos show a white utility cart in the activity room. There is a large black plastic bag on the bottom shelf of the cart. The complainant submitted additional photos of the contents of the black plastic bag to include: Documents from Enloe Hospital, care plans for residents, appointment listing for residents, patient information from Oroville Hospital, resident medication lists among others.

This allegation is substantiated.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the allegation that staff financially abused a resident 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 Gonzalez.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20240422163742
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: 06/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/02/2024
Section Cited
CCR
87506(c)(1)
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87506 (c) (1) Resident Records (c) All information and records obtained from or regarding residents shall be confidential. (1) The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents. This requirement is not met as evidenced by:
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Licensee agrees to submit a plan regarding how the facility will ensure that resident records are stored and kept confidential at all times. Licensee shall submit the plan to LPA as proof of correction.
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Based on document review the licensee did not ensure that resident confidential records were safeguarded when a large plastic bag that contained confidential resident records was located in the activity room. This poses a potential Health, Safety and Personal Rights risk to residents in care.
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The proof of correction is to be received by LPA Knight by 07/02/2024.
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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: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3