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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700575
Report Date: 04/15/2022
Date Signed: 04/18/2022 09:38:14 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/18/2022 and conducted by Evaluator Albert Johnson
COMPLAINT CONTROL NUMBER: 27-AS-20220118153621
FACILITY NAME:A PRESTIGE LIVINGFACILITY NUMBER:
502700575
ADMINISTRATOR:PIERRE-JEROME,SIMONEFACILITY TYPE:
740
ADDRESS:3208 TEHAMA CTTELEPHONE:
(209) 284-0075
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:6CENSUS: 4DATE:
04/15/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Sophia PattersonTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Resident's room was unsanitary.
Resident's hygiene needs were not met.
Staff did not provide adequate laundry services.
INVESTIGATION FINDINGS:
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Allegation: Resident's room was unsanitary.

Based on inspection of the facility by LPA Johnson on multiple unannounced visits and Modesto Police Officer Wilson on 1/7/2022, the facility was found to have a little bit of dust, however it did not appear to be conditions that are unsanitary. Officer Wilson noted in his report dated 1/7/2022, "that conditions of R1's room was not unreasonable of what I'd expect to see." The report further stated that he was unable to substaniate any unsafe living conditions.

Allegation: Resident's hygiene needs were not met.

Continued**
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022
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 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/18/2022 and conducted by Evaluator Albert Johnson
COMPLAINT CONTROL NUMBER: 27-AS-20220118153621

FACILITY NAME:A PRESTIGE LIVINGFACILITY NUMBER:
502700575
ADMINISTRATOR:PIERRE-JEROME,SIMONEFACILITY TYPE:
740
ADDRESS:3208 TEHAMA CTTELEPHONE:
(209) 284-0075
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:6CENSUS: 4DATE:
04/15/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Sophia PattersonTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Lack of supervision resulting in resident eloping from the facility.
Illegal eviction.
Staff did not provide adequate food service.
INVESTIGATION FINDINGS:
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Allegation: Lack of supervision resulting in resident eloping from the facility.

Based on records reviewed R1 is able to go into the community unassisted according to the Physician's report dated 8/26/2020, however, the facility was unaware that R1 had left the facility according to interviews with Officer Wilson of the Modesto Police department. Staff confirmed that R1 went missing around 11am or 12pm, because staff was taking care of another resident and she was the only staff working at that time when R1 went undetected for a period of time.

Continued***
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
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 8
Control Number 27-AS-20220118153621
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: A PRESTIGE LIVING
FACILITY NUMBER: 502700575
VISIT DATE: 04/15/2022
NARRATIVE
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Allegation: Illegal eviction.

Based on the letter submitted for eviction of R1, the letter is not lawful and is missing required information that would support the eviction of R1. R1 did not return to the facility after going undetected on 1/6/2022


Allegation: Staff did not provide adequate food service.

Based on records reviewed the facility did not have a menu for the residents to view or have a record of what foods had been served for the time period that R1 was living at the facility. The facility is and has provided the residents with meals but are out compliance with the maintaining a sample menu in their file. The regulations state that "Menus shall be made available for review by the residents or their designated representatives and the licensing agency upon request." The facility did not have a menu when requested by LPA Johnson on 1/27/2022 during the initial complaint investigation.

The preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. The following deficiency was observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22.

Appeal rights and report given at the conclusion of the visit
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 27-AS-20220118153621
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: A PRESTIGE LIVING
FACILITY NUMBER: 502700575
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/16/2022
Section Cited
CCR
87465(f)(1)
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Basic Services. Basic services shall at a minimum include: Care and supervision.
This requirement is not met as evidenced by Based on records reviewed and interviews
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Licensee will submit a plan on how the facility will ensure that residents' are accounted for daily and provide the
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conducted the Licensee was unaware of R1's absences, R1 was found in the community approximately 3 hours later and transported to the local hospital. This poses a health and safety risk to residents in care.
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department with a staffing schedule for the month of April POC due date 4/16/2022.
Type B
04/22/2022
Section Cited
CCR
1569.682(a)(2)(A-F)
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Health and Safety Code section 1569.682(a)(2)(A) through (F) provides:“(a) A licensee of a licensed residential care facility for the elderly shall, prior to transferring a resident of the facility to another facility or to an independent living arrangement as a result of the forfeiture of a license, as described in subdivision (a), (b), or (f) of Section 1569.19, or a change of use of the facility pursuant to the department’s regulations, take all reasonable steps to transfer affected residents safely and to minimize possible transfer trauma, and shall, at a minimum, do all of the following:
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Administrator shall review Eviction Procedures, and submit a written plan on how 30 day or 3 day evictions will be handled according to the
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(2) Provide each resident or the resident’s responsible person with a written notice no later than 60 days before the intended eviction. The notice shall include all of the following:

(A) The reason for the eviction, with specific facts to permit a determination of the date, place, witnesses, and circumstances concerning the reasons.

(B) A copy of the resident’s current service plan.
(C) The relocation evaluation.
(D) A list of referral agencies.
(E) The right of the resident or resident’s legal representative to contact the department to investigate the reasons given for the eviction pursuant to Section 1569.35.(F) The contact information for the local long-term care ombudsman, including address and telephone number. The letter submitted was not lawful.
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Title 22 Regulation requirements in the future. The plan is due to the CCL office by POC due date.
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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 27-AS-20220118153621
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: A PRESTIGE LIVING
FACILITY NUMBER: 502700575
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/22/2022
Section Cited
CCR
87555(b)(6)
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87555(b)(6) The following food service requirements shall apply:
(6) In facilities for sixteen (16) persons or more, menus shall be written at least one week in advance and copies of the menus as served shall be dated and kept on file for at least 30 days. Facilities licensed for less than sixteen (16) residents shall maintain a sample menu in their file. Menus shall be made available for review by the residents or their designated representatives and the licensing agency upon request.

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Licensee will conduct a staff training with kitchen staff to ensure understanding of regulation cited. Licensee will submit training agenda and staff sign off sheet by POC date 4/22/2022
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This regulation was not met by evidence of menus not posted, update, or out of date. This poses a
potential health risk to residents in care.
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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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 27-AS-20220118153621
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: A PRESTIGE LIVING
FACILITY NUMBER: 502700575
VISIT DATE: 04/15/2022
NARRATIVE
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Based on records reviewed and interviews with staff, it was determined that R1 can be combative and required stand by assist for completion of assistance with daily living (ADL) according to his needs and service plan dated 2/1/2021. The interviews conducted with staff confirmed that R1 was aggressive with staff and refused to have staff assist with hygiene needs and further refused to have staff in his room. Staff identified that R1 has been aggressive with other residents as well as staff members. LPA was unable to locate incident reports for aggressive acts toward staff or residents that would have been submitted to the department.

Allegation: Staff did not provide adequate laundry services.

Based on records reviewed and interviews conducted the facility established with R1 that they would not go into his room, however, R1 was required to have what he wanted washed places on the chair after he was out of the room. R1's expectation according to the staff was that his items would be washed and placed back on the chair. R1's bedding was scheduled to be washed once a week or as often as needed. Staff reported that R1's skin sheds and required additional laundry service as a result. Staff further reported that R1 would become combative when staff requested to assist with changing his bedding.


The Department has investigated the above mentioned allegations and has determined that the complaint is UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur, therefore the allegation is unsubstantiated.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/18/2022 and conducted by Evaluator Albert Johnson
COMPLAINT CONTROL NUMBER: 27-AS-20220118153621

FACILITY NAME:A PRESTIGE LIVINGFACILITY NUMBER:
502700575
ADMINISTRATOR:PIERRE-JEROME,SIMONEFACILITY TYPE:
740
ADDRESS:3208 TEHAMA CTTELEPHONE:
(209) 284-0075
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:6CENSUS: 4DATE:
04/15/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Sophia PattersonTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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2
3
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9
 Licensee did not provide resident's responsible party with a copy of Admission Agreement.
INVESTIGATION FINDINGS:
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Allegation: Licensee did not provide resident's responsible party with a copy of Admission Agreement.

Based on interviews conducted and records reviewed the facility admitted R1 from the Doctor's Medical Center hospital in Modesto, CA. on or about the 26th day of August 2020. R1 was admitted to the ER on the 24th day of August 2020, chief complaint was a 5150 hold. R1 was discharged to the facility without any listed emergency contact information or family contacts. R1 signed his admission agreement on August the 26th, 2022. The facility was unaware of the Durable Power of Attorney(POA) until family presented the documents at a later date. The POA identifies POA 1 as the trustee or appointee and POA 2 as the secondary if POA 1 is unwilling or unable to act on the behalf of R1. POA 1 did not have contact with the facility and the facility did not have contact information for POA to send or mail information.

The allegation is unfounded.
Unfounded
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 8 of 8