045000603-5-1-2023-25-AS-KHOS-CRGJT9-20230503071933

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045000603
Report Date: 05/01/2023
Date Signed: 05/01/2023 09:14:32 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/26/2023 and conducted by Evaluator Donna Gurriere

COMPLAINT CONTROL NUMBER: 25-AS-20230126173017

FACILITY NAME:	PRESTIGE ASSISTED LIVING AT OROVILLE		FACILITY NUMBER:	045000603
ADMINISTRATOR:	GEORGE DINO CORREA		FACILITY TYPE:	740
ADDRESS:	400 EXECUTIVE PARKWAY		TELEPHONE:	(530) 534-8160
CITY:	OROVILLE	STATE: CA	ZIP CODE:	95966
CAPACITY:	88	CENSUS: 33	DATE:	05/01/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	GEORGE DINO CORREA		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Staff administered an incorrect medication to a resident.
Facility staff did not notify a resident’s responsible party of an incident.

INVESTIGATION FINDINGS:

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Donna Gurriere, Licensing Program Analyst was in contact and met with George Dino Correa, Administrator.

LPA Gurriere completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID 19 infection to affirm no COVID-19 related symptoms. The administrator/staff person was contacted to complete a facility risk assessment. LPA Gurriere ensured that hand sanitizer was applied before entering the facility.

continued

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

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 4

Control Number 25-AS-20230126173017

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: PRESTIGE ASSISTED LIVING AT OROVILLE	FACILITY NUMBER: 045000603
	VISIT DATE: 05/01/2023

NARRATIVE

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Staff administered an incorrect medication to a resident.

During the interview process, the administrator and resident were interviewed. Various documents were obtained and reviewed to include Admission Agreement, Medications Log, Appraisal and Needs, Incident Report, and a list of staff names.

During the investigation process, it was reported that on 01/24/23 an error was made in that a medication technician accidentally gave a resident (Resident 1) another resident’s medication. Resident 1 was advised of the medication error; however, at the time, he declined to go to the hospital. Later that day, the resident stated that he “Didn’t feel right” and he agreed to go to the hospital. The resident was monitored and returned to the facility later in the evening.

Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be Substantiated. California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D.

Facility staff did not notify a resident’s responsible party of an incident.

During the interview process, the administrator and resident were interviewed. Various documents were obtained and reviewed to include Admission Agreement, Medications Log, Appraisal and Needs, Incident Report, and a list of staff names.

During the investigation process, it was reported that on 01/24/23 in the morning, an error was made in that a medication technician accidentally gave a resident (Resident 1) another resident’s medication. Resident 1 was advised of the medication error; however, at the time, he declined to go to the hospital.

continued

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20230126173017

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: PRESTIGE ASSISTED LIVING AT OROVILLE	FACILITY NUMBER: 045000603
	VISIT DATE: 05/01/2023

NARRATIVE

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It was reported that the resident’s family was notified of the medication error in the morning; however, the family was not advised that hospital services were offered to the resident and that he declined. During the late afternoon, the family contacted the resident and indicated that the resident was “Not himself.” It was reported that the medication technician was to contact the family to advise of the status of the resident; however, the medication technician did not. Towards the evening, the resident was taken to the hospital, was monitored and later returned to the facility when he was feeling stronger and more alert.

Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be Substantiated. California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D.

Appeal Rights were explained and provided to the facility representative listed above and an exit interview was conducted. If any of the cited deficiencies are not corrected by the noted due date; civil penalties may be assessed.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 25-AS-20230126173017

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: PRESTIGE ASSISTED LIVING AT OROVILLE	FACILITY NUMBER: 045000603
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/01/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/02/2023 Section Cited CCR 87464(d)	1 2 3 4 5 6 7	Basic Services – A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal…	1 2 3 4 5 6 7	The administrator shall ensure that staff have received additional training in an effort to avoid this type of deficiency in the future. Administrator shall submit plan of correction to the licensing agency.
	8 9 10 11 12 13 14	The licensee did not ensure that resident care was provided when a resident was given another resident’s medications.	8 9 10 11 12 13 14
Type A 05/02/2023 Section Cited CCR 87468.1(8)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities – To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs.	1 2 3 4 5 6 7	The administrator shall ensure that staff have received additional training in an effort to avoid this type of deficiency in the future. Administrator shall submit plan of correction to the licensing agency.
	8 9 10 11 12 13 14	The licensee did not ensure that the family of the resident was informed that the resident was offered to go to the hospital; however, the resident declined.	8 9 10 11 12 13 14

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: Donna Gurriere	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

LIC9099 (FAS) - (06/04)

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