585000698-8-2-2022-25-AS-TORZ-CH62W4-20220809174454

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 585000698
Report Date: 08/02/2022
Date Signed: 08/02/2022 02:42:42 PM

Unsubstantiated

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
10/26/2021 and conducted by Evaluator Kerry Hiratsuka

COMPLAINT CONTROL NUMBER: 25-AS-20211026131842

FACILITY NAME:	PRESTIGE ASSISTED LIVING AT MARYSVILLE		FACILITY NUMBER:	585000698
ADMINISTRATOR:	SMITH, AUDRE		FACILITY TYPE:	740
ADDRESS:	515 HARRIS STREET		TELEPHONE:	(530) 749-1786
CITY:	MARYSVILLE	STATE: CA	ZIP CODE:	95901
CAPACITY:	72	CENSUS: 38	DATE:	08/02/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Brandy Strahl		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Resident hit other resident in care.
Resident pushed other resident in care.
Facility is short staffed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kerry Hiratsuka, arrived at the facility unannounced to conduct a Complaint Investigation Visit. LPA conducted COVID-19 Precautionary prescreening, and wore a surgical mask while at facility. LPA was screened by Front Desk.

LPA Hiratsuka, investigated the allegation “Resident hit other resident in care; Resident pushed other resident in care; and Facility is short staffed.” LPA interviewed staff and reviewed resident's record. LPA also obtained parts of a resident's file as well.

Title 22 Regulations and the CA Health and Safety Code does not require staff to be with residents every minute of the day. The incidents did occur; however, what LPA cannot determine is the reason why the incidents occurred. The facilty has record of reaching out to the responsible party and doctor of the resident who pushed and hit the other resident. The facility has daily notes on what and how they monitored the resident in question's behavior.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20211026131842

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 MARYSVILLE	FACILITY NUMBER: 585000698
	VISIT DATE: 08/02/2022

NARRATIVE

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Staff were instructed on different approaches to the resident in question and attempted to keep the two of them apart. Staff were aware to keep the residents apart based on their interactions. The resident's care plan was adjusted multiple times.

Title 22 Regulations and the CA Health and Safety Code does not have a staff to resident ratio. The regulations both state there shall be a "sufficient amount of staff," but no other specifics. These incidents occurred in the memory care area of the facility. LPA was told during the awake hours most of the residents sit in the main common area of the memory care unit and there is a staff with them at all times or in line of sight at all times. A second staff is designated to assist the residents and if both staff are needed to assist residents then the medication tech stands in the main area with the residents. Interviews with staff did not indicate a need for extra staffing.

Based on the above, LPA cannot determine the reasons for the incidents occurring. Because the reasons cannot be determined, the allegations are unsubstantiated.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

LIC9099 (FAS) - (06/04)

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