045000603-9-11-2024-59-AS-KHOS-D9DPXM-20240923114235

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045000603
Report Date: 09/11/2024
Date Signed: 09/11/2024 11:26:51 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
09/10/2024 and conducted by Evaluator Rebecca Knight

COMPLAINT CONTROL NUMBER: 59-AS-20240910143417

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:	09/11/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Sonya Gonzalez - Executive Director		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Resident eloped from the facility due to lack of care or supervision from staff. – SUBSTANTIATED

INVESTIGATION FINDINGS:

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09/11/2024 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 conduct a complaint investigation.

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: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

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-20240910143417

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: 09/11/2024

NARRATIVE

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Resident eloped from the facility due to lack of care or supervision from staff – SUBSTANTIATED.

It was reported that Resident 1 (R1) eloped from the facility's memory care unit. Staff were not aware that R1 had eloped from the facility.

LPA reviewed a text message from a community member who states R1 was seen wandering in the parking lot of Oroville Hospital at 9:30 AM on 09/08/2024. At 10:00 AM the community member saw R1 near Highway 162. The community member called 911 at that time. A report from Oroville Police Department (OPD) dated 09/08/2024 10:00 AM recorded this telephone call. LPA reviewed a discharge summary from Oroville Hospital dated 09/08/2024 10:59 AM. LPA reviewed LIC602 Physicians Report for R1 which states they are unable to leave the facility unassisted.

Executive Director (ED) stated On 09/08/2024 at 10:52 AM staff stated that they received a telephone call from Oroville Hospital notifying that R1 was ready to be picked up. Until that point staff were unaware that R1 had eloped from the facility.

It was determined that R1 eloped from the facility without staff being aware and was out of the facility for a significant amount of time, unknown to staff. It is unknown how R1 eloped from the facility. R1 was uninjured as a result of the elopement. This allegation is substantiated.

Upon inspection of the facility’s compliance history, LPA determined that the licensee was issued a deficiency for the same violation within the past 12 months. As a result, a civil penalty was assessed in the amount of $250.00 on 09/11/2024 on the attached LIC421FC.

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: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20240910143417

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: 09/11/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/25/2024 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. In addition the licensee shall conduct a staff training concerning the importance of monitoring the residents, performing resident counts to ensure residents do not elope from the facility.
	8 9 10 11 12 13 14	This requirement is met as evidenced by: Based on interviews and records review, 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 by a community member who called 911. R1 was transported to ER for evaluation. Staff were not aware that R1 had eloped until the ER called the facility and notified staff that R1 was ready to be discharged, This poses an immediate health, welfare and safety hazard to residents in care.	8 9 10 11 12 13 14	Proof of correction to be submitted to LPA by 09/25/2024. Staff sign sheets for all related trainings and LIC500 showing increased staffing.
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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: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

LIC9099 (FAS) - (06/04)

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