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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045000603
Report Date: 07/31/2024
Date Signed: 07/31/2024 11:28:21 AM


Document Has Been Signed on 07/31/2024 11:28 AM - 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:
07/31/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Crystal Villalobos - Memory Care administratorTIME COMPLETED:
11:30 AM
NARRATIVE
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07/31/2024 11:15 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Crystal Villalobos - Memory Care administrator.

LPA reviewed a letter dated 04/29/2024 which was sent from the licensee to all residents of the facility. The letter is notifying all residents that the facility has started charging a temporary energy surcharge in the amount of $125.00 per month for the months of June, July, and August 2024. This surcharge was planned to be included as a separate line item on the resident’s monthly bill.

This surcharge is not allowable as it violates the admission agreement entered into by both parties, per licensing regulations. In lieu of the lump-sum payments, all increases in rates shall be to the monthly rate amortized over a 12-month period with advanced notification. Funds collected for this unlawful rate change shall be returned to all residents.

A deficiency is being issued this date. California Code of Regulations, (Title 22), is being cited on the attached LIC809D. Appeal rights were provided. Exit interview was conducted and the report was provided to Crystal Villalobos - Memory Care administrator and Sonya Gonzales Executive Director.

Continued on LIC809-D

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2024
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 07/31/2024 11:28 AM - 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: 07/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/14/2024
Section Cited
HSC
1569.655(b)

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§1569.655 (b) Increase in fee rates for elderly residents; 60 days’ written notice stating amount of and reasons for increase; application of section. (b) No licensee shall charge nonrecurring lump-sum assessments. The notification requirements contained in subdivision (a) shall apply to increases specified in this subdivision. For purposes of this subdivision, "nonrecurring lump-sum assessments" mean rate increases due to unavoidable and unexpected costs that financially obligate the licensee. In lieu of the lump-sum payment, all increases in rates shall be to the monthly rate amortized over a 12-month period. This requirement was not met as evidenced by:
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Licensee agrees to refund all utility surcharges that have been collected from the residents and rescind the notification that was issued to the residents on 04/29/2024. If licensee intends to require residents to pay a utility surcharge the fees must be amortized over a 12-month period and must be included in the admission agreement. As proof of correction licensee will provide LPA with a list of residents who paid the utility surcharge, the amount of surcharge the resident paid and the date a refund was issued to each resident. In addition, the licensee will update the admission agreement and submit new admission agreement to LPA.
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Based on evidence obtained it was determined that the facility is charging all residents a lump-sum utility surcharge for the months of June, July, and August 2024. This poses a potential health and safety risk to residents in care.
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The proof of correction is to be received by LPA Knight by 08/14/2024.

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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: 07/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2