045000603-6-30-2023-59-AS-KHOS-CTMPLN-20230711112501

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045000603
Report Date: 06/30/2023
Date Signed: 06/30/2023 02:11:33 PM

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
04/18/2023 and conducted by Evaluator Rebecca Knight

COMPLAINT CONTROL NUMBER: 59-AS-20230418085731

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: 38	DATE:	06/30/2023
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Sonya Gonzalez- Executuive Director		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not administer resident's medication as prescribed. - SUBSTANTIATED

INVESTIGATION FINDINGS:

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

06/30/2023 12:30 PM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with Executive Director Sonya Gonzales. The purpose of this visit was to deliver the results of a complaint investigation.

During the course of the investigation 1 former Executive Director, 1 memory care director, 1 resident, and 2 facility staff were interviewed. LPA requested and reviewed the following documents: related incident reports, EMAR, Physician’s report, Admission Agreement, for 1 resident, staff list with telephone numbers, client list.

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: 06/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023

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 8

Control Number 59-AS-20230418085731

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: 06/30/2023

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 did not administer resident's medication as prescribed. - SUBSTANTIATED

It was reported that Resident 1 (R1) was not dispensed their prescribed pain medication.

LPA reviewed EMAR for the month of April 2023 which showed that R1 did not receive their prescribed pain medication starting with their PM dose on 4/10/2023 and did not receive their pain medication at all from that date through 4/16/2023.

LPA review of R1’s Service Plan dated 04/02/2023 revealed that R1 has pain in their hands.

R1 stated the facility had just started giving R1 their pain medication but it had not started to work yet. R1 stated that was probably because R1 had not been on it for so long when they took R1 off of the pain medication. R1 stated their hand still hurts.

Staff stated that R1 missed a couple of days of pain medication because it was not refilled.

The Expressions Director stated that R1 did not receive their pain medication from 4/10/2023 through 4/16/2023 because the medication ran out. Staff sent for refills and found out the script had expired, then contacted R1’s doctor.

Former Executive Director (ED) stated R1 does take pain medication and starting on 4/10/2023 through 4/16/2023 R1 missed their pain medication. ED stated the facility did not have the pain medication in house and notified R1’s physician.

It was determined that R1 did not receive their prescribed pain medication. This allegation is substantiated.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above 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 Gonzalez.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 8

Control Number 59-AS-20230418085731

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: 06/30/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/14/2023 Section Cited CCR 97456	1 2 3 4 5 6 7	87465 (c)(2) Incidental Medical and Dental Care - ((c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for ... medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to provide documentation of refill to LPA. Licensee agrees to conduct training on the requirement to ensure that prescription refills are fulfilled before the resident’s current supply runs out. This training is required of all staff and management who are responsible for ensuring that prescription refills are fulfilled before the resident’s supply runs out. Licensee shall submit signed staff attendance sheet as proof of correction.
	8 9 10 11 12 13 14	Based on interviews and document review it was determined that Resident 1’s supply of prescription pain medication ran out and R1 was without their prescribed pain medication for 1 week. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14	The proof of correction is to be received by LPA Knight by 07/14/2023.
	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: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 8

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
04/18/2023 and conducted by Evaluator Rebecca Knight

COMPLAINT CONTROL NUMBER: 59-AS-20230418085731

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: 38	DATE:	06/30/2023
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Sonya Gonzales - Executuive Director		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not notify responsible party of resident's change of condition.
Staff did not report incident to responsible party.
Resident was left in soiled linens for an extended period of time.
Staff did not safeguard resident's personal belongings.

INVESTIGATION FINDINGS:

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

Unsubstantiated

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: 06/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 8

Control Number 59-AS-20230418085731

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: 06/30/2023

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 did not notify responsible party of resident's change of condition. – UNSUBSTANTIATED.

It was reported that the facility failed to report a change in condition to Resident 1’s (R1) family which resulted in hospital stays. Complainant did not return LPA’s telephone calls so no further details could be obtained regarding this allegation.

LPA reviewed incident report dated 02/27/2023 which reported that R1 was transported to the hospital via EMS and admitted with a diagnosis of sepsis. Incident report stated that R1’s family was at bedside during this time.

LPA reviewed incident report dated 03/27/2023 which reported that R1 was transported to the hospital via EMS for lethargy and high temperature. R1 was admitted for evaluation and treatment. Incident report states that R1’s family was notified.

Resident stated they had recently been sent out to the hospital and stated that it could not be true that their family was not notified because they knew everything about R1 in the hospital.

Staff 2 stated that R1 had a change of condition and believed the family was notified. Staff 3 stated they did not know if the family was notified.

The Expressions Director stated the reason R1 was sent out was because of a change in condition.

Former Executive Director stated they sent R1 out to the hospital because they were not feeling well. ED stated they called the EMT and notified the family.

This allegation is unsubstantiated.

Continued on LIC9099-C

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 8

Control Number 59-AS-20230418085731

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: 06/30/2023

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 did not report incident to responsible party. - UNSUBSTANTIATED

It was reported that the facility failed to notify R1’s family that R1 had been sent to the hospital. Complainant did not return LPA’s telephone calls so no further details could be obtained regarding this allegation.

Resident stated they had recently been sent out to the hospital and stated that it could not be true that their family was not notified because they knew everything about R1 in the hospital.

Staff stated that that the med tech who was on duty told them the family was notified.

Expressions Director stated the family was notified before R1 left to go to the hospital.

This allegation is unsubstantiated.

Continued on LIC9099-C

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023

LIC9099 (FAS) - (06/04)

Page: 6 of 8

Control Number 59-AS-20230418085731

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: 06/30/2023

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

Resident was left in soiled linens for an extended period of time. - UNSUBSTANTIATED

It was reported that R1 has periods of bowel and bladder incontinence and this has left R1 lying in wet linens before. No dates of occurrences were provided. Complainant did not return LPA’s telephone calls so no further details could be obtained regarding this allegation.

Staff stated R1 is checked every 2 hours but did not think the checks were documented.

Resident 1 stated they have not been left lying in wet linens, that R1 calls staff if R1 has an accident and they come right away. R1 stated they do not tolerate that.

The Expressions Director stated that staff check on R1 every 2 hours during the night and their brief is checked during those 2-hour checks which is documented with the safety checks under safety monitoring.

Former Executive Director (ED) stated staff check on R1 every 2 hours during the night and this is documented in the facility’s Point-Click-Care electronic medical records system. ED stated that staff check R1’s brief during the 2 hour checks but this is not documented.

This allegation is unsubstantiated.

Continued on LIC9099-C

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023

LIC9099 (FAS) - (06/04)

Page: 7 of 8

Control Number 59-AS-20230418085731

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: 06/30/2023

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 did not safeguard resident's personal belongings -UNSUBSTANTIATED

It was reported that R1’s bottom denture went missing. Complainant did not return LPA’s telephone calls so no further details could be obtained regarding this allegation.

LPA review of LIC602 Physician’s Report dated 10/05/2022 Physical Health Status Section C. “Wears Dentures” is blank (neither Yes nor No are checked).

Resident stated their bottom denture went missing shortly after they were made. R1 stated the denture did not fit right and R1 kept taking them out because they were annoying. R1 stated as far as they knew their bottom denture went missing while they were living at the facility. R1 stated their bottom denture has not been found.

Staff 2 stated since they started working at the facility (December 2022) R1 has not had bottom dentures. Staff 3 was not aware that R1 was missing their bottom denture.

The Expressions Director stated they did not know if R1’s bottom dentures were missing and no one has asked her about them.

Former Executive Director stated that they were never told that R1’’s bottom denture was missing.

This allegation is unsubstantiated.

Although the allegations may have happened or are 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. A copy of the report was provided to Executive Director Sonya Gonzalez.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023

LIC9099 (FAS) - (06/04)

Page: 8 of 8