342700987-4-24-2024-27-AS-KVIA-D4N3YN-20240424184009

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700987
Report Date: 04/24/2024
Date Signed: 04/24/2024 06:50:46 PM

Document Has Been Signed on 04/24/2024 06:50 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	PRESTIGE CARE HOMES 1		FACILITY NUMBER:	342700987
ADMINISTRATOR:	VIDAN BARIAS		FACILITY TYPE:	740
ADDRESS:	9847 LINCOLN VILLAGE DRIVE		TELEPHONE:	(916) 802-7610
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95827
CAPACITY:	6	CENSUS: 6	DATE:	04/24/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Ariel Alcantara		TIME COMPLETED:	05:30 PM

NARRATIVE

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Unannounced Annual Inspection visit was made by Licensing Program Analyst (LPA) Kimberly Viarella to this facility on 04/24/24. LPA identified herself to the Caregiver on duty, explained the purpose of the visit, and asked to speak with the Designated Facility Administrator (DFA). LPA was told the DFA was on vacation so the LPA met with the Designee, per LIC 308, Ariel Alcantara and a brief interview followed.

LPA noted the DFA's certificate, # 6058642740 expires on 1/27/25.

The inspection began in the kitchen. All knives and sharps were locked and inaccessible to residents in care. The food supply was adequate for 2-day perishable and 7-day nonperishable. Opened packages in the refrigerator were dated appropriately. The fire extinguisher was last serviced on 11/29/23 by the State Fire Marshall and was also in compliance.

LPA inspected the resident 6 bedrooms and 1 staff bedroom. All resident rooms had the required furniture, furnishings and lighting to be in compliance at this time.

LPA noted soap, paper towels and trash cans with lids in the 3 bathrooms. Shampoo, conditioner, lotions and other hygiene items were in the shower as well. The hot water temperature was measured at 126.7 degrees Fahrenheit and was not in compliance. There was a caution sign posted on the mirror, but regulations state that the water for resident use should not exceed 120 degrees Fahrenheit. 5 out of the 6 residents in care at this time are non-ambulatory, but one resident still had access to this bathroom. LPA instructed the Designee to turn the temperature down to between 105 and 120 degrees in order to return them to compliance.

The exterior of the building was inspected by the LPA. There were no bodies of water present and the yard was completely fenced in. LPA observed that all screens and gutters were in good repair. There was 1 storage shed with a lock that contained miscellaneous furniture and storage items. There was also a patio area for residents to enjoy.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PRESTIGE CARE HOMES 1	FACILITY NUMBER: 342700987
	VISIT DATE: 04/24/2024

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The LPA observed medications were stored in a large locked cabinet in the kitchen and inaccessible to residents in care. LPA observed that each resident had a clearly marked covered bin that displayed their name. LPA checked a sample of medications and all were current at the present time. A review of the First Aid kit by the LPA found it to be complete and in compliance.

A file review was completed next. LPA reviewed 8 staff files and they were all in compliance. LPA reviewed 6 resident files and learned that 1 resident was bedridden and not on hospice. The facility did not have a fire clearance to admit a bedridden resident. This violation is cited on the LIC 421M page. Civil Penalties were assessed during this visit.

According to the California Code of Regulations, Title 22, the following deficiencies were observed and cited on the LIC 809D page.

Due to technical difficulties, this LPA was not able to leave a printed copy of this report today, however, it will be emailed to the Licensee/Administrator along with the APPEAL RIGHTS within 24 hours.

Exit Interview.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/24/2024 06:50 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PRESTIGE CARE HOMES 1	FACILITY NUMBER: 342700987
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87606(c)

Care of Bedridden Residents

(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, a staff interview as well as a record review, the licensee did not comply with the section cited above with 1 out of 6 residents in care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/25/2024
	Plan of Correction
1 2 3 4	The Licensee shall notify the fire department and apply for a fire clearance.

Type A

Section Cited

CCR

87705(g)

(g) As required by Section 87468(a)(12), residents with dementia shall be allowed to keep personal grooming and hygiene items in their own possession, unless there is evidence to substantiate that the resident cannot safely manage the items. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review the licensee did not comply with the section cited above as 2 out of 6 residents in care at this time were not allowed access to personal hygiene items per their LIC 602s. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/25/2024
	Plan of Correction
1 2 3 4	The Licensee will ensure that these items are removed and made inaccessible from the residents who are at risk. The staff removed items before the LPA left the premises.

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: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024

LIC809 (FAS) - (06/04)

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