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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315002995
Report Date: 05/08/2025
Date Signed: 05/08/2025 12:24:07 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/28/2025 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20250228150820
FACILITY NAME:PRESTIGE ENVIRONS FOR THE AGESFACILITY NUMBER:
315002995
ADMINISTRATOR:HEARD, TERESITAFACILITY TYPE:
740
ADDRESS:5350 NORTHCLIFF DRIVETELEPHONE:
(916) 625-1012
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:6CENSUS: 1DATE:
05/08/2025
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Tess Heard, Administrator TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Resident was not administered medications as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver (2) additional findings to a complaint received on February 28, 2025. LPA met with Teresita "Tess" Heard, Administrator, stating the reason for today's inspection. Also present was staff, Treylon Heard. (1) resident was resting in her room.

During the course of the investigation, LPA reviewed documentation related to prior resident (R1), including, but not limited to, the physician's report and medication documentation. LPA interviewed (2) family members of (R1), (3) faciility staff and (1) hospice nurse, who attended to (R1) regularly. The results of the investigation are as follows:

Resident (R1) moved to the care home on November 14, 2024, under the care of hospice. The physician's report notes (R1) had a diagnosis of Mild Cognitive Impairment (MCI), fall weakness, motor impairment paralysis and incontinence. Additionally the report notes that (R1) could be confused, was able to communicate and follow directions at times, and needed help with all Activites of Daily Living (ADL's).
*cont on 9099C-1..
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
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 6
Control Number 59-AS-20250228150820
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 ENVIRONS FOR THE AGES
FACILITY NUMBER: 315002995
VISIT DATE: 05/08/2025
NARRATIVE
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9099C-1.. Allegation: Resident was not administered medications as prescribed. The allegation states that resident (R1), who was under hospice care, was observed by visitors to be alert and talkative one day and the next day would be barely speaking, and almost in a coma state.

The administrator stated (R1had a stroke and was paralyzed on the left side, would sometimes eat and drink lightly, "was fully aware of what's going on and did not have Dementia"The Administrator stated (R1) took "pre-filled meds" from their hospice company and was "very cooperative, and never refused medications. Additionally, the administrator stated that "two cousins visited everyday for 2-3 hours, there were a total of about ten different visitors, adding "the visitors never said anything that (R1) seemed over-medicated". The administrator confirmed the facility uses a Medication Administration Record (MAR), documents all PRN medications administered, and that (R1) took Ativan every (2) hours as well as Halidol.

Staff (S1) confirmed that he helped with hospice medications, set up the medications per (R1's) chart, and (R1) "took her medications". (S1) stated (R1) was "normal, always sleepy", he assisted with pain medications and there were no problems. Staff (S2) confirmed that (R1) took Ativan and Halidol and there were no issues with medications being administered, asserting (R1) "surprised me at her age- she was in and out of lucid moments and at times didn't make sense".

A family member who visited (R1) regularly stated (R1) did not like taking some of the medications- it was a challenge- (R1) did not like them". The family member explained "there were days where (R1) was adamant and didn't know who I was, and there were days when I called my cousin and said (R1) is not going to make it, and the next day (R1) was chipper". The family member stated "Some days (R1) seemed to be more heavily medicated than the other days- it was a roller coaster" and asked the nurse about the medications, who said she would follow up with facility staff to ensure the medications were being given at the proper time.

The hospice nurse confirmed she spoke with the Administrator, at least twice, about how to correctly administer (R1's) medications by following the prescribed dosages. The nurse explained how the hospice Medical Director provided additional training on following the prescribed dosages, mainly with the medication, Ativan. The nurse indicated that the facility was administering medications correctly according to the prescribed frequency, but the mg/dosage was sometimes more or less than what was prescribed.
*cont on 9099C-2..
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 59-AS-20250228150820
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 ENVIRONS FOR THE AGES
FACILITY NUMBER: 315002995
VISIT DATE: 05/08/2025
NARRATIVE
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9099C-2 LPA reviewed medication documentation from November 2024- January 2025. The Centrally Stored Medication Record (LIC622) notes a prescription was filled on November 13, 2024 Lorazapem (Ativan) 0.5 mg tablet- One tablet to be given by mouth, every (6) hours as needed. On November 14, 2024, a new prescription of Ativan 1mg tablet (30 tablets) was logged for resident to take 1 tablet every (4) hours, as needed, for anxiety and agitation. On December 2, 2024, a refill bottle of Ativan 1mg (60) tablets was logged.

The PRN log for November 2024 shows Ativan (quantity not listed) was administered once a day from November 14, 2024 through November 22, 2024 and was given again on November 26, 2024, once at 8:00 am and again at 9:00 pm.

The PRN log for December 2024 notes 1 tablet of medication, Ativan was administered at least daily from December 1-5.

LPA reviewed a hospice physician's order, dated December 6, 2024, where the order for Lorazapem (Ativan) 1 mg, every (4) hours was discontinued and an order for Ativan .5 mg, every 4 hours was started.

The next administered doses were documented as follows:

Dec 10- 9:00 am- 0.5 mg for restlessness
Dec 11- 8:00 am- 1/2 tablet for restlessness and Dec 11- 5:00 pm- 1/2 tablet for restlessness
Dec 12 7:30 am- 1/2 tablet for restlessness and Dec 12 5:30 pm- 1 tablet for restlessness

Based on information obtained during the investigation, the Department find the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) citation is issued on the 9099-D page.

Exit interview with the Administrator. Copy of report and appeal rights provided
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 59-AS-20250228150820
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 ENVIRONS FOR THE AGES
FACILITY NUMBER: 315002995
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
05/09/2025
Section Cited
CCR
87465(c)(2)
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87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:
(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
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Licensee/Administrator agree to ensure all staff have completed medication training on following prescription orders for PRN medications.

Ensure hospice is counting the medications at least weekly, making sure the facilty's records match the hospice's records.
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Based on interviews conducted and documenation reviewed, the Licensee did not ensure the PRN medication Ativan .5 mg was administered, per doctor's orders, on December 12, 2024 (5:30 pm), which posed an immediate health and safety risk to residents in care.
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Documentation due to the Deparment, by 5/22/25, by email or fax.
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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.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/28/2025 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20250228150820

FACILITY NAME:PRESTIGE ENVIRONS FOR THE AGESFACILITY NUMBER:
315002995
ADMINISTRATOR:HEARD, TERESITAFACILITY TYPE:
740
ADDRESS:5350 NORTHCLIFF DRIVETELEPHONE:
(916) 625-1012
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:6CENSUS: DATE:
05/08/2025
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Tess Heard, Administrator TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff inappropriately touched resident.
INVESTIGATION FINDINGS:
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During the course of the investigation, LPA reviewed documentation related to prior resident (R1), including, but not limited to the physician's report and medication documentation. LPA interviewed (2) family members of (R1), (3) faciility staff and (1) hospice nurse, who attended to (R1) regularly. The results of the investigation are as follows:

The allegation states that (R1) was inappropriately touched by a care staff during an incontinent check on/around November 22, 2024. Interviews with a second family member who visited regularly and the hospice nurse revealed that there were no concerns about (R1) ever being inappropriately touched. The hospice nurse confirmed that (R1) used a foley catheter and it was never observed to be displaced, or altered and there was additionally no bruising observed.

The Administrator stated (R1) was scheduled to receive multiple incontinent checks daily and that she and staff (S1) would change the catheter bag. *cont on 9099A
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 59-AS-20250228150820
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 ENVIRONS FOR THE AGES
FACILITY NUMBER: 315002995
VISIT DATE: 05/08/2025
NARRATIVE
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9099A-C-1.. The administrator explained that the catheter was changed "three times by the hospice nurse due to leaking and that due to (R1's) bone structure" the nurse put tape to secure the catheter on the left side to secure it. The administrator stated (R1) "was very cognizant about what was going on and midnight was the last time she was checked until the morning".

The hospice nurse stated (R1) definitely had Dementia and (R1) would tell stories that were not always credible. The hospice nurse indicated she did not believe (R1) was inappropriately touched by staff.

Based on information obtained, LPA finds the allegation to be UNFOUNDED--meaning that the allegation was false, could not have happened and/or is without reasonable basis.

Exit interview. Copy of report provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6