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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045000603
Report Date: 07/01/2021
Date Signed: 07/01/2021 02:39:43 PM

Document Has Been Signed on 07/01/2021 02:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 OROVILLEFACILITY NUMBER:
045000603
ADMINISTRATOR:GOLLIHAR, JEFFREYFACILITY TYPE:
740
ADDRESS:400 EXECUTIVE PARKWAYTELEPHONE:
(530) 534-8160
CITY:OROVILLESTATE: CAZIP CODE:
95966
CAPACITY: 88CENSUS: 40DATE:
07/01/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jeff Gollihar, AdministratorTIME COMPLETED:
03:00 PM
NARRATIVE
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On 7/1/21 at 10:00 AM, Licensing Program Analyst (LPA) Jaclyn Avila conducted an unannounced case management visit concerning an incident report that was submitted to licensing on 6/14/21. LPA met with Jeff Gollihar, administrator and Hannah Sadrin, LVN and explained the purpose of the visit. Prior to initiating the 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 Hannah 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: N-95 Mask. LPA completed the facility screening.

The incident report detailed that on 6/12/21, Staff (S1) forced resident (R1) out of bed and per R1, S1 dragged him out of bed. Police responded to the incident.

This department conducted an investigation into the incident which consisted of document review and interviews which revealed that on 6/12/21 at approximately 7:30 AM, S1 pulled R1 out of bed although R1 said no and resisted being pulled from the bed. R1 was pulled from bed and placed in R1's chair. S1 did this by grabbing R1 by the arm and leg while stating S1 did not have time for R1. As a result R1 cried and made a report to the on duty med tech. Additional staff witnessed the incident, R1's response to the incident and stated S1 hated the residents and working at the facility. Administrative staff contacted Oroville Police Department who responded to the facility on 6/12/21. The facility terminated S1 on 6/24/21 as a result of this incident.

LPA spoke with administrator and staff regarding mandated reporting and completing the SOC 341. LPA left LIC 855 (Declaration form) for each staff to be completed by 7/5/21.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted and appeal rights provided.
SUPERVISORS NAME: Rayna L Bryson
LICENSING EVALUATOR NAME: Jaclyn Avila
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/01/2021 02:39 PM - It Cannot Be Edited


Created By: Jaclyn Avila On 07/01/2021 at 01:22 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/02/2021
Section Cited
CCR
87468.2(a)(8)

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87468.2(a)(8)-Personal Rights-To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.
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Licensee agrees to conduct an in-service training on personal rights and mandated reporting with an outside agency. Licensee will show proof of registration by COB on 7/2/21 and will provide proof of training by 7/30/21.
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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
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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:Rayna L Bryson
LICENSING EVALUATOR NAME:Jaclyn Avila
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2021


LIC809 (FAS) - (06/04)
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