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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045000603
Report Date: 09/19/2023
Date Signed: 09/19/2023 12:32:58 PM


Document Has Been Signed on 09/19/2023 12:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 OROVILLEFACILITY NUMBER:
045000603
ADMINISTRATOR:GONZALES, SONYAFACILITY TYPE:
740
ADDRESS:400 EXECUTIVE PARKWAYTELEPHONE:
(530) 534-8160
CITY:OROVILLESTATE: CAZIP CODE:
95966
CAPACITY:88CENSUS: 38DATE:
09/19/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Mariah Mitzel- Resident Services DirectorTIME COMPLETED:
01:00 PM
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09/19/2023 11:50 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Mariah Mitzel- Resident Services Director. Executive Directro Sonya Gonsalez was unavailable during the visit. Today’s visit is regarding an incident that occurred on 09/06/2023 and was reported to licensing on 09/12/2023.

It was reported that on 09/06/2023 at 1:30 PM Staff checked on Resident 1 (R1) who was found standing naked and slurring their words. R1 stated they were in pain and had taken some medication “from a friend.” 911 was called and R1 was transported to the local emergency room for evaluation. R1’s family and physician were notified. R1 was admitted to hospital with a diagnosis of toxic metabolic encephalopathy.

During the visit LPA interviewed 1 staff, toured resident room and requested the following documents: Physicians Report, Needs and Services Plan, MAR for 1 resident.

Needs further investigation. No deficiencies were cited during today's visit.

A copy of the report was provided to Mariah Mitzel - Resident Services Director.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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