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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045000644
Report Date: 05/23/2023
Date Signed: 05/23/2023 12:26:41 PM


Document Has Been Signed on 05/23/2023 12:26 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:PRESTIGE ASSISTED LIVING AT CHICOFACILITY NUMBER:
045000644
ADMINISTRATOR:CORREA, GEORGEDINOFACILITY TYPE:
740
ADDRESS:1351 E. LASSEN AVENUETELEPHONE:
(530) 899-0814
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY:79CENSUS: 54DATE:
05/23/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Paul BlanchardTIME COMPLETED:
12:36 PM
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Licensing Program Analyst (LPA) Kerry Hiratsuka and Licensing Program Analyst (LPA) Ivan Avila arrived at the facility unannounced to conduct a case management in response to an incident report submitted yesterday. The incident was a wall unit HVAC system being changed and a spark occurred while being changed. Smoke happened but no damage occurred. Fire department was called, arrived, and cleared the room for occupancy. Room was deep cleaned and is occupied.

No deficiencies cited during todays visit.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2023
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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