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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 585000698
Report Date: 10/07/2021
Date Signed: 10/07/2021 02:52:28 PM



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
02/03/2021 and conducted by Evaluator Pheej Cheng
COMPLAINT CONTROL NUMBER: 25-AS-20210203091948
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
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Audre Smith; AdministratorTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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1) Staff not meeting resident’s needs.
INVESTIGATION FINDINGS:
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On 10/7/21 at 11:15 AM, Licensing Program Analyst (LPA) Cheng conducted an unannounced complaint investigation visit regarding the above allegations and met with Administrator Audre Smith. 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.

Continuation on 9099C.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 8
Control Number 25-AS-20210203091948
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: 10/07/2021
NARRATIVE
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1) Staff not meeting Resident’s needs.

Based on interview statements, facility internal progress notes, R1 incident reports, and facility policy/procedures documents obtained, the following information was obtained. Facility internal progress notes regarding R1 shows that there were entries dated 5/16/2020 and 5/17/2020 where R1 complained of pain, nausea, and vomiting. LPA Mai Thao requested for all of R1’s incident reports. Facility was only able to produce an incident reported dated 2/1/2021; which was unrelated to the incident being questioned. Facility’s Emergency Response and First Aid Policy outlines that when a resident has “any sudden change in condition characterized by lethargy”, staff are to evaluate the resident, stay with the resident, and call 911. Facility was unable to provide any documentation that an assessment was conducted, and the resident was being monitored for any further changes in condition. Facility was unable to provide any documentations that R1’s primary doctor was notified of R1’s change in condition and that medical attention was given per facility policy. Facility failed to meet resident’s needs by not observing resident for changes, failure to contact R1’s primary physician, and/or seeking medical attention in a timely manner as directed in facility policy when a change of condition occurs.

Based on LPA information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

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
LIC9099 (FAS) - (06/04)
Page: 2 of 8
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
02/03/2021 and conducted by Evaluator Pheej Cheng
COMPLAINT CONTROL NUMBER: 25-AS-20210203091948

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
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Audre Smith; AdministratorTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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1) Staff mismanaging residents medication
INVESTIGATION FINDINGS:
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Based on statements, R1’s centrally stored medication record log (CSMR), medication administration record, and doctor’s orders, the department obtained the following information. It was alleged that staff failed to administer R1’s anti-acid and that R1 was out of a prescribed medication. R1’s centrally stored medication log and doctor’s order does not show any records of R1 being prescribed an anti-acid medication. Statements obtained from facility’s med techs show that they do not recall R1 ever being prescribed or have administered R1 any anti-acid medication. Med tech’s interviewed stated that all medications are given as prescribed by the resident’s physicians and each dose administered is documented in the facility’s Electronic Medication Administration Record (e-MAR).

Continuation on LIC 9099C.
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 25-AS-20210203091948
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: 10/07/2021
NARRATIVE
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In regard to R1 not being administered a routine prescribed medication due to it being out, LPA determined the following. Facility’s Supply/Medication Recorder Tracking log shows that R1’s routine prescribed medication was empty on 10/20/2020 and R1’s son was notified prior to the medication being empty. R1’s CSMR show that a new order of R1’s routine prescribed medication began on 10/20/2020. Upon further review, R1’s CSMR had discrepancy in terms of start date of R1’s prescribed routine medication. However, R1’s eMAR indicates that all doses were given on time and that none were missed. S1 confirmed that there are discrepancies after reviewing R1’s CSMR and that the facility’s eMAR is an official document used to track the actual administering of medication. LPA Mai Thao interviewed 10 of 10 residents and statements obtained confirmed that all of their medications were administered on time. LPA’s were unable to determine if R1’s prescribed routine medication was empty and not administered as the allegation stated.

Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.
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
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 25-AS-20210203091948
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
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
CCR
87466
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87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. This requirement was not met as evidenced by:
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Licensee agree to conduct an in-service training regarding observation of residents for changes in condition along with providing the necessary care required for those changes and submit proof of all training materials and signatures of participates to LPA by POC date.
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Licensee did not observe for changes and provide appropriate assistance to those changes for 1 of 1 resident which poses an immediate health and safety risk for 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
LIC9099 (FAS) - (06/04)
Page: 3 of 8
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
02/03/2021 and conducted by Evaluator Pheej Cheng
COMPLAINT CONTROL NUMBER: 25-AS-20210203091948

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
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Audre Smith; AdministratorTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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1) Staff did not provide laundry services.
2) Staff not providing adequate food service.
3) Staff did not notify resdient's authorized representative of change in resdient's condition.
INVESTIGATION FINDINGS:
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1) Staff did not provide basic laundry services.

Based off interview statements received, residents stated that all laundry services are conducted by facility staff. Staff washes resident’s sheets at least once a week. Residents interviewed stated that staff have never had any issues changing and washing their bed sheets more than once a week if needed. LPA Mai Thao was unable to interview R1 as R1 is no longer at the facility and refused to speak LPA Mai Thao. Staff statements indicate that there’s a schedule for laundry services for residents; however, staff would provide laundry services for those who need it and that is not scheduled.
Unfounded
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 25-AS-20210203091948
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: 10/07/2021
NARRATIVE
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1) Staff not providing adequate food service.

Based on interview statements and R1’s internal progress notes obtained, the department determined the following information. R1 is on a diabetic/cardiac diet. Staff interviewed confirmed that R1 was on a special diet and that R1’s family was very strict about it as well. Staff members stated that R1’s family members would be present outside of R1’s room almost every single day and observed almost every meal served. R1’s diet would be restricted and would approve of what type of food along with how much food is being provided. Staff interviewed confirmed that they are aware that resident’s have the right to refuse food and the facility is not allowed to deny food to residents. Due to R1’s diet, food alternatives are offered and can be provided in both full and half-servings at resident’s request. R1’s internal progress notes indicate that facility waited for confirmation of R1’s family approval for R1’s meals/portions on multiple occasions between 05/2020 and 06/2020. R1’s internal progress notes also indicate that R1 was being served dinner meals on multiple occasions and finished R1’s meals without any issue.

Continuation on LIC 9099C.

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
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 25-AS-20210203091948
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: 10/07/2021
NARRATIVE
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2) Staff did not notify resident’s authorized representative of change in resident’s condition.

Based on staff and RP interview statements and R1’s home health notes obtained, the department determined the following information. R1 has an ongoing rash prior to being admitted to the facility. R1 was receiving home health services for the rash since 5/15/2020 and was eligible for discharge on 12/4/2020 if rash has healed. R1’s internal progress notes indicate that the rash was still present and ongoing up until R1 was moved out of the facility. R1’s internal progress notes also indicate that on 11/3/2020, R1’s family was informed of redness and as rash. R1 received home health services for the rash starting 11/5/2020. R1’s home health notes visit notes indicate that R1’s son was consulted by home health regarding using different briefs for R1. S1 stated that authorized parties are notified during initial observation of an incident. If the incident requires on-going observation and that if there are no changes, family are not notified as there is nothing changes to report. R1 was discharged from home health services due to improvements but current treatment was to continue per home health instructions. R1 was removed from the facility on 1/27/2021 by R1’s authorized party.

This agency has investigated the complaint allegations listed above. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint.

Exit interview conducted and copy of the report was provided 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
LIC9099 (FAS) - (06/04)
Page: 8 of 8