045000644-11-30-2021-25-AS-KHOS-CAEHHP-20220106051305

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045000644
Report Date: 11/30/2021
Date Signed: 11/30/2021 12:17:33 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/17/2021 and conducted by Evaluator Donna Gurriere

COMPLAINT CONTROL NUMBER: 25-AS-20210617084440

FACILITY NAME:	PRESTIGE ASSISTED LIVING AT CHICO		FACILITY NUMBER:	045000644
ADMINISTRATOR:	BAKER, BECKY		FACILITY TYPE:	740
ADDRESS:	1351 E. LASSEN AVENUE		TELEPHONE:	(530) 899-0814
CITY:	CHICO	STATE: CA	ZIP CODE:	95973
CAPACITY:	79	CENSUS: 49	DATE:	11/30/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	JOE MICELI		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Lack of supervision resulting in an unwitnessed fall and hospitalization.

INVESTIGATION FINDINGS:

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

Donna Gurriere, Licensing Program Analyst was in contact and met with Joe Miceli, Administrator. It was alleged that the Facility did not provide basic services to a resident; the Facility neglected a resident resulting in resident being malnourished; Lack of supervision resulting in an unwitnessed fall and hospitalization; the Facility did not report to the resident’s representative, as required; and the Facility did not respond as required to the resident’s change in condition.

LPA Gurriere completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID 19 infection to affirm no COVID-19 related symptoms. The administrator/staff person was contacted to complete a facility risk assessment. LPA Gurriere ensured that hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. Additionally, LPA Gurriere was screened by a staff person upon entering the facility.

continued

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021

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 2

Control Number 25-AS-20210617084440

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: PRESTIGE ASSISTED LIVING AT CHICO	FACILITY NUMBER: 045000644
	VISIT DATE: 11/30/2021

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

Lack of supervision resulting in an unwitnessed fall and hospitalization.
During the interview process, an administrator and eight staff persons were interviewed.
The current administrator was not present during the time of the allegations; however, the facility did have an interim administrator. Some staff persons were not available for an interview and the resident (Resident 1) was not interviewed as she has moved out of state. Numerous documents were obtained to include the resident’s Physician’s Report, Admission Agreement, medications list, hospital and physician records.

It was reported by several staff persons that the resident did sustain a fall. It was stated that the resident was independent, went to clean her cat litter box and was bending over when she fell. The resident was able to get herself back in bed and then called for staff assistance. The staff responded and called Emergency Services. Emergency Services arrived at the facility and took the resident to the hospital. It was reported that the resident suffered a fractured hip. There is not enough evidence to support that the fall was due to the staff persons lack of supervision.

Overall, it could not be proven that there was a Lack of supervision resulting in an unwitnessed fall and hospitalization. Although the allegation may have happened, or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated.

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2