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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585000698
Report Date: 10/07/2021
Date Signed: 10/07/2021 03:07:54 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 MARYSVILLEFACILITY NUMBER:
585000698
ADMINISTRATOR:SMITH, AUDREFACILITY TYPE:
740
ADDRESS:515 HARRIS STREETTELEPHONE:
(530) 749-1786
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY:72CENSUS: 42DATE:
10/07/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Audre Smit; AdministratorTIME COMPLETED:
01:15 PM
NARRATIVE
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On 10/7/21 at 12:45 PM, Licensing Program Analyst (LPA) Cheng conducted an unannounced case management visit regarding deficiencies discovered related to complaint # #25-AS-20210203091948. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask and gloves. Additionally, LPA was screened by front receptionist Ande.

During the investigation of complaint #25-AS-20210203091948, it was discovered that the facility failed to report R1’s change in condition on 5/16/2020 and 5/17/2020 to R1’s responsible party, primary physician, and to Community Care Licensing. It was also noted that there were discrepancies in R1’s Centrally Stored Medication Record Log (CSMR). Although R1’s Electronic Medication Administration Record (eMAR) shows that R1’s prescribed routine medication was administered, R1’s CSMR start dates and quantity does not coincide with the eMAR as 4/28/2020 to 5/3/2020 were unaccounted for in the CSMR. Also, facility was unable to provide an explanation as to why start date for R1’s prescribed routine medication was within a 27-day time frame when the medication for each order has a supply for 30 days. LPA Mai Thao discussed this with S1 and S1 confirmed and was unable to provide an explanation.

Deficiencies are cited per California Code of Regulations, Title 22, and listed on LIC 809D. Failure to submit Proof of Corrections (POC's) by Plan of Correction date may result in civil penalties.

Exit interview conducted and a copy of report was given along with appeal rights.

SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (915) 263-4813
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/18/2021
Section Cited

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87211 Reporting Requirements (a)(1) A written report shall be submitted to the licensing agency and to the person responsible...(D) Any incident which threatens the welfare, safety or health of any resident..This requirement was not met as evidenced by:
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Based on R1's records review, Licensee did not report a change of condition for 1 of 1 residents in care which poses a potential health and safety risk for resident in care.
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Type B
10/18/2021
Section Cited

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87465 Incidental Medical and Dental Care (h)(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year...this requirement was not met as evidenced by:
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Based on medication records review, Licensee did not maintain accurate records for 1 of 1 resident's centrally stored medication log which poses a potential health and safety risk to resident 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: Maribeth SentyTELEPHONE: (915) 263-4813
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2021
LIC809 (FAS) - (06/04)
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