045000644-7-11-2024-59-AS-LMUZ-D7JMM8-20240726094331

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045000644
Report Date: 07/11/2024
Date Signed: 07/11/2024 02:52:16 PM

Unsubstantiated

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
04/23/2024 and conducted by Evaluator Jaynae Boyles

COMPLAINT CONTROL NUMBER: 59-AS-20240423101340

FACILITY NAME:	PRESTIGE ASSISTED LIVING AT CHICO		FACILITY NUMBER:	045000644
ADMINISTRATOR:	BLOW, SCOTT		FACILITY TYPE:	740
ADDRESS:	1351 E. LASSEN AVENUE		TELEPHONE:	(530) 899-0814
CITY:	CHICO	STATE: CA	ZIP CODE:	95973
CAPACITY:	79	CENSUS: 60	DATE:	07/11/2024
		UNANNOUNCED	TIME BEGAN:	02:50 PM
MET WITH:	Administrator- Scott Blow		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff did not prevent resident from verbally assaulting resident in care.

INVESTIGATION FINDINGS:

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On 0X/0X/2024, Licensing Program Analyst Jaynae Boyles made an unannounced visit to the facility and met with administrator. The purpose of this visit was to deliver the results of a complaint investigation.
During the course of the investigation the administrator, six (6) residents and nine (9) staff were interviewed. LPA reviewed the following documents for R1: Electronic Medication Administration Record

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 administrator.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae Boyles	TELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024

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

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20240423101340

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 CHICO	FACILITY NUMBER: 045000644
	VISIT DATE: 07/11/2024

NARRATIVE

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LPA investigated, “Staff did not prevent inappropriate interactions between residents”.
LPA interviewed the Administrator who reported that he and the staff were aware that an incident occurred between R1 and R2, in that R2 raised her voice at R1. The facility was unable to identify why the incident occurred. Administrator reported that immediately, a plan was developed and implemented by the team to ensure that R1 and R2 have limited interaction. All staff interviewed reported that they were aware of the incident between R1 and R2, and that a plan was developed for staff to help alleviate any future incidents between the residents. Although an incident did occur between R1 and R2, R1 was not harmed, and staff took immediate action.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae Boyles	TELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024

LIC9099 (FAS) - (06/04)

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