045000644-8-27-2024-59-AS-KHOS-D92L7R-20240912083045

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045000644
Report Date: 08/27/2024
Date Signed: 08/27/2024 10:23:50 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, 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
05/29/2024 and conducted by Evaluator Jaynae Boyles

COMPLAINT CONTROL NUMBER: 59-AS-20240529142533

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: 61	DATE:	08/27/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Administrator- Scott Blow		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Facility staff are not following resident needs and service plan.

INVESTIGATION FINDINGS:

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On 0X/XX/2024 Licensing Program Analyst 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.

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. An exit interview was conducted. A copy of the report was provided to administrator.

Substantiated

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: 08/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024

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-20240529142533

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: 08/27/2024

NARRATIVE

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LPA investigated, “Facility staff are not following the residents needs and service plan”. The resident (R1) had recent breast cancer treatment which required surgery. The resident returned to the facility with home health checking the resident daily. On May 25, 2024, the facility and R1 reported to the LPA that the resident had their blood pressure checked three times, one of which was checked on the left arm. R1 reported that they had an alert bracelet to not use the left arm for any medical procedure. The facility reported that the resident did not have an alert bracelet on their body on this date.

Due to the blood pressure being checked on the left side of the body, the resident began to bleed from the surgical wound. R1 reported that she did not know why blood pressure was being checked at the facility. The facility reported that the discharge paperwork from the hospital did not indicate that the resident had an alert bracelet, or the need mfrequent blood pressure readings. The facility did not update the resident needs and services plan after the resident had surgery as they indicated that there were no changes in care stated on the discharge paperwork from the hospital.

When the resident returned from the hospital, there was a change in the resident’s condition (resident had surgery) and the administrator did not ensure that a new Appraisal/Needs and Services Plan (LIC 625) was updated as required. For reasons clearly unknown, the staff took the resident’s blood pressure, which caused the resident’s wounds to bleed. The regulations state that the pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae Boyles	TELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20240529142533

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/27/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/27/2024 Section Cited CCR 87463(a)	1 2 3 4 5 6 7	Reappraisals - The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition.This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The facility will educate and train staff to ensure that they are only providing services that are on the resident needs and services plan. The facility will provide training to the staff that performed the procedure incorrectly. The facility will provide the POC to the LPA within two weeks.
	8 9 10 11 12 13 14	The facility provided services that were not included in the needs and services plan which caused the resident to sustain injuries.	8 9 10 11 12 13 14
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	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: Jaynae Boyles	TELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024

LIC9099 (FAS) - (06/04)

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