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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585000698
Report Date: 03/16/2022
Date Signed: 03/16/2022 12:38:48 PM


Document Has Been Signed on 03/16/2022 12:38 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:PRESTIGE ASSISTED LIVING AT MARYSVILLEFACILITY NUMBER:
585000698
ADMINISTRATOR:STRAHL, BRANDYFACILITY TYPE:
740
ADDRESS:515 HARRIS STREETTELEPHONE:
(530) 749-1786
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY:72CENSUS: 39DATE:
03/16/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Vanessa Villa, Expression DirectorTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Mai Thao, arrived at the facility unannounced on 03/16/2022 to conduct a case management visit and met with Vanessa Villa, Expression Director and explained purpose of visit. Prior to 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. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Mask. In addition, Staff screened LPA prior to entering the facility.

On 2/4/2022, Licensing received an incident report from the facility reporting an incident that occurred at the facility on 1/14/2022, 1/25/2022, and 2/4/2022. It was reported that Resident 1 (R1) was found on the floor on 1/14/2022 and 1/25/2022. On 1/25/2022, R1 began having unusual behaviors. R1 received a Compute Tomography (CT) scan on 2/3/2022 and results indicated a fractured pelvic.

During today's visit, LPA discussed the incident with Expression Director, reviewed R1's files, and collected copies of R1 's files. LPA observed in facility notes from 1/14/2022 to 2/24/2022. LPA observed in facility documents that R1 was sent out to the Emergency Room (ER) and came back with no new orders on 1/14/2022. LPA observed in facility notes that facility continue to monitor R1 change in condition throughout the whole time. LPA observed in facility documents that R1 had an updated care plan on 2/24/2022. Expression Director stated that the facility and R1's doctor are working together to set up Physical Therapist with R1.

No citations were observed during today's visit. Exit Interviews conducted and a copy of this report was left at the facility with Vanessa Villa, Expression Director.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Mai ThaoTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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