342700987-4-13-2023-27-AS-KGOD-CQUU8U-20230413152206

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700987
Report Date: 04/13/2023
Date Signed: 04/13/2023 03:22:15 PM

Document Has Been Signed on 04/13/2023 03:22 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
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: 6	DATE:	04/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Vidan Barias		TIME COMPLETED:	03:45 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 4/13/23 at 1:15pm Licensing Program Analyst (LPA) Kevin Gould arrived at Prestige Care Homes 1 for the purpose of conducting a required 1 year annual inspection. LPA met with licensee, Vidan Barias and together conducted a tour of the home. LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed a sliding screen door from bedroom #3 that has a tear around the handle and is in need of replacement/repair, The faucet in one bathroom is not functioning, a small hole in the hallway needing to be patched, and the closet in bedroom #1 is off the rails and needs to be repaired/replaced. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA measured the water temperature, temperature measured at 135 degrees F which does not meet the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents. LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 500 personnel report, LIC 610E Emergency Disaster Plan, Current Administrator Certificate and Client Roster Per California Code of Regulations, Title 22 the following deficiencies are cited during today's inspection. An exit interview was conducted, and a copy of this report and appeal rights were left at the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

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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Document Has Been Signed on 04/13/2023 03:22 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs testing of hot water temperature, the licensee did not comply with the section cited above as the hot water temperature recorded today was 135 degrees which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2023
	Plan of Correction
1 2 3 4	LPA observed licensee turn down hot water temperature. LPA will return to confirm the hot water temperature meets regulations.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/13/2023 03:22 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation during the inspection, the licensee did not comply with the section cited above as LPA observed the Screen door on bedroom number 1 needs to be replaced, the faucet in the bathroom was not working, hole in wall in the hallway and the closet door in bedroom #1 needs to be rpaired which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/30/2023
	Plan of Correction
1 2 3 4	Licensee has agreed to have the items listed repaired by hte POC due date of 4/30/23.

Type B

Section Cited

CCR

87506(b)(15)

Resident Records

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs review of resident records, the licensee did not comply with the section cited above in 1 out of 3 files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/21/2023
	Plan of Correction
1 2 3 4	Licensee has agreed to update the admission agreement for resident by the POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

LIC809 (FAS) - (06/04)

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