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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045000644
Report Date: 02/04/2025
Date Signed: 02/04/2025 10:58:56 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
10/07/2024 and conducted by Evaluator Donna Gurriere
COMPLAINT CONTROL NUMBER: 59-AS-20241007115453
FACILITY NAME:PRESTIGE ASSISTED LIVING AT CHICOFACILITY NUMBER:
045000644
ADMINISTRATOR:BLOW, SCOTTFACILITY TYPE:
740
ADDRESS:1351 E. LASSEN AVENUETELEPHONE:
(530) 899-0814
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY:79CENSUS: 59DATE:
02/04/2025
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:SCOTT BLOWTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff did not properly transfer a resident in care resulting in resident sustaining a fracture.
Staff did not seek medical attention in a timely manner.
INVESTIGATION FINDINGS:
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On 02/04/25 Donna Gurriere, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 10/07/24. LPA Gurriere met with Scott Blow, Administrator and explained the purpose of the visit.

Staff did not properly transfer a resident in care resulting in resident sustaining a fracture.

During the interview process, several staff persons, residents, and the resident’s (Resident 1) service coordinator were interviewed. Documents were obtained to include Admission Agreement, Care Plan, Individual Program Plan (IPP) Assessment and Service Plan, Physician’s Report, Incident Reports, Enloe Medical Records, Progress Notes, staff names/shift schedules, and staff names and cell numbers.


continued
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
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 5
Control Number 59-AS-20241007115453
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: 02/04/2025
NARRATIVE
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During the investigation process, it was reported that staff assist the resident (Resident 1) in her daily activities to include transferring from the wheelchair to the toilet. In the past, the resident was able to bear her own weight by assisting with the transfer by grabbing onto the grab bar and using her good arm to set herself down or pull herself up off the toilet. On the day of the incident, 10/03/24 the resident appeared to be too weak to use her arm during the transfer. It was reported that it was common knowledge to the staff that the resident’s one arm was immobile because of a childhood diagnosis. During the transfer, the two staff persons went “arm-to-arm” with the resident and then heard a “popping” sound come from the resident’s arm. The resident said “ouch” and the staff asked her if she was all right. The resident responded that she was fine; however, was known not to complain.

The following day on 10/04/24 the resident complained to staff that her arm was hurting and that she was in pain. A determination was made to send the resident to the hospital for an evaluation. It was reported that during the toileting transfer, the resident sustained an acute, displaced, and impacted fracture of the right humerus neck.

According to the facility’s service plan, it states that staff may use a “gait belt for all transfers for safety of a resident.” During the interview process, it was stated that residents should not be pulled by the arm during transfers. Staff admitted they were not trained to use arm-to-arm transfers. A gait belt was not used during the transfer.

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.



The administrator was informed that a civil penalty is under review and may be assessed at a future date according to Health and Safety Code §1569.49. This report and rights to appeal were discussed with the administrator.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 59-AS-20241007115453
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: 02/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/05/2025
Section Cited
CCR
87411(a)
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Personnel Requirements – General - Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…
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The administrator agrees to train all staff on transferring residents, using a gait belt and agrees to submit the signed list of staff persons and the training materials to the licensing agency. The administrator agrees to re-evaluate those residents that may benefit by using a gait belt when transferring.
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This requirement was not met as evidenced by: Based on interviews and records reviewed, the licensee did not ensure that staff were competent and trained to transfer a resident from the wheelchair to the toilet.
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 This is considered a serious violation, and the licensee shall be served a $500.00 civil penalty this date.
Type A
02/05/2025
Section Cited
CCR
87464(d)
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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…
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The administrator agrees to provide training to all care providing staff as to how and when to conduct an assessment of a resident that has sustained an injury. The administrator agrees to submit the signed list of staff persons and the training materials to the licensing agency.
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This requirement was not met as evidenced by: Based on interviews and records reviewed, the licensee did not ensure that the staff checked the resident’s arm for redness, swelling or for a loss of range of motion. A lapse of time occurred when the resident was not sent out to the hospital.
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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 CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 59-AS-20241007115453
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: 02/04/2025
NARRATIVE
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Staff did not seek medical attention in a timely manner.

During the interview process, staff persons, residents, and the resident’s (Resident 1) service coordinator were interviewed. Documents were obtained to include Admission Agreement, Care Plan, Individual Program Plan (IPP) Assessment and Service Plan, Physician’s Report, Incident Reports, Enloe Medical Records, Progress Notes, staff names/shift schedules, and staff names and cell numbers.

On 10/03/24 the resident appeared to be too weak to use her arm during a transfer. It was reported that it was common knowledge to the staff that the resident’s one arm was immobile because of a childhood diagnosis. During the transfer, two staff persons went “arm-to-arm” with the resident and then heard a “popping” sound come from the resident’s arm. The resident said “ouch” and the staff asked her if she was all right. The resident responded that she was fine; however, was known not to complain.

The following morning on 10/04/25 approximately 24 hours later, the resident asked for pain medication due to her arm being in pain. There was no indication that during the incident, the staff checked the resident’s arm for redness, swelling, or for a loss of range of motion. The resident reported to staff that her arm was in pain and the staff arranged to have Emergency Services contacted and transported the resident to the hospital. The resident sustained an acute, displaced, and impacted fracture of the right humerus neck during the transfer of two staff persons.

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.

Previously Chico Ventures LLC & Prestige Senior Living LLC.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
10/07/2024 and conducted by Evaluator Donna Gurriere
COMPLAINT CONTROL NUMBER: 59-AS-20241007115453

FACILITY NAME:PRESTIGE ASSISTED LIVING AT CHICOFACILITY NUMBER:
045000644
ADMINISTRATOR:BLOW, SCOTTFACILITY TYPE:
740
ADDRESS:1351 E. LASSEN AVENUETELEPHONE:
(530) 899-0814
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY:79CENSUS: 59DATE:
02/04/2025
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:SCOTT BLOWTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
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9
Staff are not following resident's care plan.
INVESTIGATION FINDINGS:
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On 02/04/25 Donna Gurriere, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 10/07/24. LPA Gurriere met with Scott Blow, Administrator and explained the purpose of the visit.

Staff are not following resident's care plan.

During the interview process, staff persons, residents, and the resident’s (Resident 1) service coordinator were interviewed. Documents were obtained to include Admission Agreement, Care Plan, Individual Program Plan (IPP) Assessment and Service Plan, Physician’s Report, Incident Reports, Enloe Medical Records, Progress Notes, staff names/shift schedules, and staff names and cell numbers.

During the investigation, the resident’s most recent care plan was reviewed and was dated 05/21/24 which stated, “Staff will provide physical assistance with transferring resident.” At the time, of the injury, the staff were following the resident’s care plan, as required.

Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above findings are Unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5