045000603-7-22-2021-25-AS-MSEY-C56UY4-20210722155920

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045000603
Report Date: 07/22/2021
Date Signed: 07/22/2021 02:08:42 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/22/2021 and conducted by Evaluator Misty Valencia

COMPLAINT CONTROL NUMBER: 25-AS-20210222114019

FACILITY NAME:	PRESTIGE ASSISTED LIVING AT OROVILLE		FACILITY NUMBER:	045000603
ADMINISTRATOR:	STRAHL, BRANDY		FACILITY TYPE:	740
ADDRESS:	400 EXECUTIVE PARKWAY		TELEPHONE:	(530) 534-8160
CITY:	OROVILLE	STATE: CA	ZIP CODE:	95966
CAPACITY:	88	CENSUS: 38	DATE:	07/22/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Executive Director (ED) Jeff Gollihar		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are chemically restraining resident.
Facility not following resident's hospice care plan.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 7/22/2021, Licensing Program Analyst (LPA) Misty Valencia conducted an unannounced complaint investigation visit regarding the above allegations and met with Executive Director (ED) Jeff Gollihar. Prior to initiating the complaint visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by front desk receptionist.

continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kevin Mknelly	TELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Misty Valencia	TELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

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 5

Control Number 25-AS-20210222114019

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: PRESTIGE ASSISTED LIVING AT OROVILLE	FACILITY NUMBER: 045000603
	VISIT DATE: 07/22/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Staff are chemically restraining resident.

During interview with Executive Director and records reviewed, it was determined that the Staff are chemically restraining resident to be unsubstantiated. After interview and record reviews, it was concluded that R1 was given all prescriptions as prescribed from the hospice physician. LPA reviewed R1’s MARS, observed that the Haloperidol 5mg was prescribed as a PRN and taken as needed. LPA reviewed records and R1 did not even receive the Haloperidol every day, only as needed. LPA reviewed MARS/Medication list and did not observe any errors, missed medications, and was all signed by staff. The preponderance of evidence standard has not been met. The allegation is unsubstantiated.

Facility not following resident's hospice care plan.

During interview with Executive Director and records reviewed, it was determined that the Facility not following resident's hospice care plan to be unsubstantiated. After interview and record reviews, it was concluded that the facility was following hospice care plan as requested from Enloe Hospice. R1 was given all prescriptions as prescribed from the hospice physician. R1 was being seen from a physician at the facility while on hospice. The preponderance of evidence standard has not been met. The allegation is unsubstantiated.

Based on the information obtained, records reviewed, and interviews conducted, the above allegations are Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are Unsubstantiated.

An exit interview was conducted with the ED. There are no citations given at this time.

SUPERVISOR'S NAME: Kevin Mknelly	TELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Misty Valencia	TELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/22/2021 and conducted by Evaluator Misty Valencia

COMPLAINT CONTROL NUMBER: 25-AS-20210222114019

FACILITY NAME:	PRESTIGE ASSISTED LIVING AT OROVILLE		FACILITY NUMBER:	045000603
ADMINISTRATOR:	STRAHL, BRANDY		FACILITY TYPE:	740
ADDRESS:	400 EXECUTIVE PARKWAY		TELEPHONE:	(530) 534-8160
CITY:	OROVILLE	STATE: CA	ZIP CODE:	95966
CAPACITY:	88	CENSUS: 38	DATE:	07/22/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Executive Director (ED) Jeff Gollihar		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff threw a glass of water in resident's face

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kevin Mknelly	TELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Misty Valencia	TELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

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 25-AS-20210222114019

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: PRESTIGE ASSISTED LIVING AT OROVILLE	FACILITY NUMBER: 045000603
	VISIT DATE: 07/22/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Staff threw a glass of water in resident's face.

During interview with Executive Director, and records reviewed, it was determined that Staff threw a glass of water in resident's face to be Substantiated. During interview and records reviewed it was concluded that S1 did throw water at R1. S1 admitted to throwing water at R1. S1 was terminated and never picked up her last check, the facility had to mail it to S1. The preponderance of evidence standard has been met. The allegation is Substantiated.

Based on the evidence obtained, 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 LIC 9099D. Appeal rights are provided, and a closure interview was conducted.

SUPERVISOR'S NAME: Kevin Mknelly	TELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Misty Valencia	TELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 25-AS-20210222114019

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: PRESTIGE ASSISTED LIVING AT OROVILLE	FACILITY NUMBER: 045000603
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/22/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/22/2021 Section Cited CCR 87468.2(a)(8)	1 2 3 4 5 6 7	-Personal Rights-To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.	1 2 3 4 5 6 7	POC has already been corrected as of today training has been sceduled for 7/27/21 by the ombudsman for mandating reporting and abuse. Also training has been completed on 2/21/21 and 4/20/21 for resident rights.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Interview and documentation. Licensee failed to protect 1 of 1 resident from physical abuse. 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: Kevin Mknelly	TELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Misty Valencia	TELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 5