342700987-4-21-2021-27-AS-KGOD-C2AVLC-20210421163144

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700987
Report Date: 04/21/2021
Date Signed: 04/21/2021 04:31:55 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	PRESTIGE CARE HOMES 1		FACILITY NUMBER:	342700987
ADMINISTRATOR:	MARINAS, MARCIAL		FACILITY TYPE:	740
ADDRESS:	9847 LINCOLN VILLAGE DRIVE		TELEPHONE:	(916) 802-7610
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95827
CAPACITY:	6	CENSUS: 5	DATE:	04/21/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator, Marcial Marinas		TIME COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 4/21/21 at 9:00am Licensing Program Analyst (LPA) Kevin Gould conducted a tele-prelicensing inspection for Prestige Care Homes 1. LPA Gould met with Administrator Marcial Marinas and the Licensee. There are currently five (5) residents in placement (see LIC-811, dated 4/21/21). The Licensee is requesting a capacity of six (6) LPA observed the approved fire clearance is for six (6) residents, six (6) resident may be non-ambulatory. The home is located in a residential area with 6 bedrooms, 3 bathrooms, living room, dining room, receiving room, kitchen, Staff office and break room and laundry and backyard with no pools or bodies of water. Facility layout is as follows: Bedroom #1: Occupied by R1, with a capacity for one (1) resident. LPA observed one hospital style bed, adequate storage and lighting. Smoke detector is working and operational. Bedroom #2: Vacant, to be occupied by one (1) resident. LPA observed one hospital style bed, adequate storage and lighting. Smoke detector is working and operational. Bedroom #3: Occupied by R2, with a capacity for one (1) resident. LPA observed one hospital style bed, adequate storage and lighting. Smoke detector is working and operational. Bedroom #4: Occupied by R3, with a capacity for one (1) resident. LPA observed one hospital style bed, adequate storage and lighting. Smoke detector is working and operational. Bedroom #5: Occupied by R4, with a capacity for one (1) resident. LPA observed one hospital style bed, adequate storage and lighting. Smoke detector is working and operational. Bedroom #6: Occupied by R5, with a capacity for one (1) resident. LPA observed one hospital style bed, adequate storage and lighting. Smoke detector is working and operational. Bathroom #1: is a full bathroom equipped with toilet, sink and shower with appropriate grab bars. Bathroom #2: is a full bathroom equipped with toilet, sink and roll in shower with appropriate grab bars. Bathroom #3: is a full bath with toilet, sink and shower located in the staff break room.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PRESTIGE CARE HOMES 1	FACILITY NUMBER: 342700987
	VISIT DATE: 04/21/2021

NARRATIVE

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LPA observed adequate seating for residents in the kitchen and an appropriate number of plates, cups and silverware to meet the residents needs. Licensee has an appropriate supply of non-perishable food supply and a 2 day supply of fresh perishable foods. LPA observed the medication storage in the kitchen cabinet with no other food items and locked in accordance with Title 22 regulations. LPA also observed a small fridge for storing medications requiring refrigeration in the hallway with a lock and no other food items stored inside. LPA also observed sharp knives locked and inaccessible to residents and cleaning supplies locked away inaccessible to residents. The facility has a working fire extinguisher and fully stocked first aid kit located in the kitchen. Family room was observed with plenty of seating, TV and a staff desk and cabinets for files all with locks per regulations to ensure confidentiality. Laundry room with washer and dryer.

LPA observed the back yard to be free of any debris or hazards to residents in care. LPA observed plenty of seating in the backyard with table and umbrella for shade. LPA also observed a storage shed in the back yard with a lock.

Facility will not transport residents in a facility vehicle or personal vehicle.

An exit interview was conducted with the licensee and a copy of this report was mailed to the facility for signature. Facility meets regulations to proceed with licensure pending application review.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2021

LIC809 (FAS) - (06/04)

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