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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585000698
Report Date: 07/10/2024
Date Signed: 07/10/2024 04:23:57 PM


Document Has Been Signed on 07/10/2024 04:23 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 MARYSVILLEFACILITY NUMBER:
585000698
ADMINISTRATOR:BRANDY STRAHLFACILITY TYPE:
740
ADDRESS:515 HARRIS STREETTELEPHONE:
(530) 749-1786
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY:72CENSUS: 29DATE:
07/10/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Megan SharpTIME COMPLETED:
04:30 PM
NARRATIVE
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LPA Hiratsuka conducted this unannounced visit. LPA learned this building was used as an evacuation site for the Oroville Prestige from July 2, 2024, to July 5, 2024, due to the Thompson fire.

LPA learned this on July 8, 2024, after everyone was back to their facility. Today, LPA interviewed Interim Executive Director (IED) Megan Sharp. IED stated they bought air mattresses, food, supplies, and brought in extra staff to ensure the residents' comfort and safety. LPA did not observe any issues with the way the facility absorbed the residents from the other facility temporarily.

Title 22 regulations require a facility to report many different types of incidents that occur to Community Care Licensing Division as well as to other appropriate agencies and responsible parties. The facility that was being evacuate did the appropriate reporting. This facility did not report to Community Care Licensing Division they were hosting the residents who were being evacuated. This is the Title 22 Regulation 87211(a)(2) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.

Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code. Failure to correct shall result in civil penalties. appeal rights left
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 07/10/2024 04:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 MARYSVILLE
FACILITY NUMBER: 585000698

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/10/2024
Section Cited
CCR
87211(a)(2)

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 Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel, or visitors,
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By 08/10/2024, Licensee shall submit a written plan of correction on how and when they shall ensure appropriate agencies and responsible parties are notified during any type of catastrophe.
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shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. Based on record review, the licensee did not comply with this because they didn't notify all the Community Care Licensing offices involved, which poses/posed a potential health, safety or personal rights risk to persons 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: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2024
LIC809 (FAS) - (06/04)
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