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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045000644
Report Date: 09/14/2022
Date Signed: 09/14/2022 11:27:39 AM


Document Has Been Signed on 09/14/2022 11:27 AM - 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,
, CA



FACILITY NAME:PRESTIGE ASSISTED LIVING AT CHICOFACILITY NUMBER:
045000644
ADMINISTRATOR:MICELI, JOSEPHFACILITY TYPE:
740
ADDRESS:1351 E. LASSEN AVENUETELEPHONE:
(530) 899-0814
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY:79CENSUS: 54DATE:
09/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Eric Perry - Executive DirectorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Ruth Wallace arrived at the facility unannounced to conduct a Required -1 Year Inspection Visit utilizing the infection control domain, LPA met with Executive Director (ED) and explained the purpose of the visit. Prior to initiating the annual inspection, 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: surgical masks. Additionally, LPA Wallace was screened by facility staff.

LPA Wallace and ED toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, dining room, resident bedrooms, bathrooms, activity room, storage areas and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA Wallace and the ED completed the infection control domain and facility was found to be in substantial compliance at this time. LPA observed the smoke/monoxide alarms to be in working order and the fire extinguishers are fully charged which expire 10/15/2022. Facility is conducting quarterly fire drills and the last one was conducted 8/16/2022. The hot water measured 114.3*F in resident room which is within the required range of 105-120*F. All staff were observed to be wearing surgical masks. Facility entrance is equipped with proper COVID-19 signage and screening station. Facility has a mitigation plan in place should a COVID positive case occur. Facility has sufficient supply of perishable food, non-perishable food, medication, and PPE.

LPA reviewed 7 of 54 resident records and LPA reviewed medications of 2 residents comparing with Centrally Stored Medication Record and physician orders. LPA reviewed 6 staff records and all have health screen and TB results. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed all have current first aid certificates.

No deficiencies cited today from California Code of regulations, Title 22.

Exit interview conducted and copy of report was given to ED.

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2022
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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