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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700575
Report Date: 10/07/2022
Date Signed: 10/10/2022 11:04:14 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
07/14/2022 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220714150547
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: 5DATE:
10/07/2022
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Simone Pierre-JeromeTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff are verbally abusive to residents
Facility does not administer medications as prescribed
Staff does not provide meals timely
Staff is stealing valuables from residents
INVESTIGATION FINDINGS:
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On 10/07/2022 at 2:15pm, Licensing Program Analyst (LPA) Arielle Pascua arrived at this facility unannounced to deliver complaint findings. LPA Pascua was greeted by staff member, Sophia Patterson and Facility Designated Administrator, Simone Pierre-Jerome and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings regarding the allegations above. Current census was 5.
Allegation: Staff are verbally abusive to residents.
Based on 3 staff interviews, 3 out of 3 staff members stated that they have not heard any staff members yell or become verbally abusive to the residents. 3 out of the 3 staff members interviewed stated when they are experiencing behaviors from residents they use different approaches to calm residents down. LPA attempted to interview 3 family members and 2 out of 3 family members refused to provide any information. 1 out of 3 family members did not return the LPA's phone call. LPA attempted to interview 5 residents, 5 out of 5 residents were unreliable due to their medical condition.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
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 2
Control Number 27-AS-20220714150547
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: 10/07/2022
NARRATIVE
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Allegation: Facility does not administer medications as prescribed
LPA reviewed Medication Administration Records(MAR) and Physicians Reports for all 4 residents who resided at the facility from 03/2022-07/2022. LPA also conducted interviewed 2 staff members who were responsible in administering medication. One staff member stated that MARs are reviewed and signed daily and every time medication is given. One staff member also stated that MARs are audited by the Facility Designated Administrator and one other staff member at the end of every week. LPA did not find any evidence of residents not receiving medication as prescribed after reviewing medical and medication records.

Allegation: Staff does not provide meals timely
Based on 3 staff interviews, 3 out of 3 staff members stated that they provide 3 meals a day and provide snacks in between. 1 out of 3 staff members stated that breakfast may be served between the hours of 8:00am-9:00am because some residents like to sleep in but will provide them breakfast when they wake up. 3 out of 3 staff members stated that lunch is served at 12:00pm and dinner is always at 5:00pm. 3 out of 3 staff members state that they each provide at least one meal and one snack during their shift. LPA interviewed 5 residents, 5 out of 5 residents stated that they like to eat the food provided from the facility.

Allegation: Staff is stealing valuables from residents.
Based on 3 staff interviews, 3 out of 3 staff members stated that they are unaware of any valuables that have been stolen from the residents. 2 out of 3 staff members who handle admissions to the facility stated that they ensure that the residents fill out an inventory list upon arrival at the facility. 2 out of 3 staff members also stated that they encourage residents and their loved ones to not bring anything of value into the facility. LPA attempted to interview 5 residents, 5 out of 5 residents were unreliable due to their medical condition.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.

There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the Facility Designated Administrator, Simone Pierre-Jerome.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2