045000644-1-14-2025-59-AS-KHOS-DD4KUS-20250120071314

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045000644
Report Date: 01/14/2025
Date Signed: 01/14/2025 10:30:54 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
11/26/2024 and conducted by Evaluator Donna Gurriere

COMPLAINT CONTROL NUMBER: 59-AS-20241126164249

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: 59	DATE:	01/14/2025
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	SCOTT BLOW		TIME COMPLETED:	10:35 PM

ALLEGATION(S):

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Staff are mismanaging resident’s medications.

INVESTIGATION FINDINGS:

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On 01/14/25 Donna Gurriere, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 11/26/24. LPA Gurriere met with Scott Blow, Administrator and explained the purpose of the visit.

Staff are mismanaging resident’s medications.

During the interview process the administrator and the health care coordinator, were interviewed twice; once by LPA Benson and once by LPA Gurriere; records were reviewed. In addition, a Cottonwood Drug Pharmacy staff person was interviewed. Documents were obtained to include the resident’s (Resident 1) Medication Administrative Records (MARs), the Admission Agreement, Individual Program Plan (IPP), Prescription Orders, Assessment and Service Plan, and the Physician’s Report.

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: 01/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

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-20241126164249

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: 01/14/2025

NARRATIVE

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During the investigation process, the health care coordinator and LPA Gurriere went through the resident’s prescription orders and the MARs. It was indicated that there were missed days of medication prescribed to the resident. Medication review is as follows:

Hydrochlorothiazide (HCTZ)

Prescription Order Date: 07/31/24
Facility Start Date: 08/16/24
The order was not filled for 16 days.

Ketoconazole

Prescription Order Date: 08/20/24
Facility Start Date: 08/22/24
The order was not filled for two days.

Tramadol

Prescription Order Date: 05/10/24 - 05/15/24, prescribed as a Pro Re Nata (PRN).
New Prescription Order Date: 05/17/24 - 05/18/24, Routine.
Discontinued Order Date: 05/20/24.
Per the Medication Administration Records (MARs) the prescription was followed and documented as prescribed.

The Cottonwood Drug Pharmacy contact person stated that when their pharmacy receives a prescription order from the physician before 11:30 a.m., the pharmacy will deliver the prescription order the same day. If the prescription order comes in and is marked "Urgent," and it is after 11:30 a.m. the pharmacy will deliver the same day. Generally, if the prescription order comes in, in the afternoon, the pharmacy will deliver the following day.

continued

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20241126164249

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: 01/14/2025

NARRATIVE

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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 is found to be Substantiated. California Code of Regulations, (Title 22), is 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: 01/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 59-AS-20241126164249

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: 01/14/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/15/2025 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	Incidental Medical and Dental Care - A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed.	1 2 3 4 5 6 7	The administrator agrees to develop a plan of correction to be submitted to the licensing agency advising how this type of deficiency will be avoided in the future.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on interviews and records reviewed, the licensee/administrator did not ensure that a resident received her medication when the medication was prescribed.	8 9 10 11 12 13 14
	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: Donna Gurriere	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

LIC9099 (FAS) - (06/04)

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