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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045000644
Report Date: 01/17/2024
Date Signed: 01/17/2024 02:04:12 PM


Document Has Been Signed on 01/17/2024 02:04 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 61DATE:
01/17/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:50 AM
MET WITH:Administrator- Scott BlowTIME COMPLETED:
02:15 PM
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LPA arrived unannounced to the facility to conduct a case management meeting regarding an incident that was reported to the Department.

LPA, Administrator, Health Services Director met and discussed the challenges with the resident. The facility is working with the ombudsman to resolve the issues with the resident. Furthermore the Administrator is conducting an investigation of the incident and will share with the LPA the results of the investigation. LPA was provided with the staff members resume and job application. LPA was given a copy of the residents 602.


No deficiencies are being cited as a result of todays visit. Exit interview conducted and a copy of this report was left with the Administrator.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024
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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