045000603-9-15-2022-25-AS-RWAE-CJAP8K-20220915110541

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 045000603
Report Date: 09/15/2022
Date Signed: 09/15/2022 11:05:47 AM

Document Has Been Signed on 09/15/2022 11:05 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
CCLD Regional Office,
, CA

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: 36	DATE:	09/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:20 AM
MET WITH:	Georgedino Correa - Executive Director		TIME COMPLETED:	11:15 AM

NARRATIVE

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Licensing Program Analyst (LPA) Ruth Wallace arrived at the facility unannounced to conduct a Required -1 Year Inspection Visit utilizing the infection control domain. LPA met with Executive Director (ED) and explained the purpose of the visit. Prior to initiating the annual inspection 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. 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 the receptionist.

LPA and ED toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, four (4) resident bedrooms, common restrooms, resident laundry rooms, and the memory care unit. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and ED completed the infection control domain and facility was found to be in substantial compliance at this time. Kitchen area was toured. Food preparation stations, dishwashing station, and food storage units were reviewed. Food supply was reviewed for adequate 2 day perishable supply and 7 day nonperishable supplies. Medication room, located on the first floor, was toured.
LPA observed the smoke/monoxide alarms to be in working order and the fire extinguishers are fully charged which expire 9/8/2023. Facility is conducting quarterly fire drills and the last one was conducted . The hot water measured 113.4*F which is within the required range of 105-120*F.
LPA reviewed 5 of 36 resident records. LPA reviewed 5 staff records and all have health screen and TB results. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed current first aid certificates and staff #2 was missing current first aid certificate.

One deficiency cited today according to California Code of regulations, Title 22.

Exit interview conducted with ED. A copy of reports and appeal rights were given to ED.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

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 09/15/2022 11:05 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
CCLD Regional Office,
, CA

FACILITY NAME: PRESTIGE ASSISTED LIVING AT OROVILLE	FACILITY NUMBER: 045000603
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

Personnel Requirements - General

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in staff #2 does not have current First Aid Certificate which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/22/2022
	Plan of Correction
1 2 3 4	Licensee agrees to submit copy of staff #2 current First Aid Certificate via email to Licensing Program Manager Laura Munoz by Plan of Correction Date 9/22/2022. laura.munoz@dss.ca.gov

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC809 (FAS) - (06/04)

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