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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397004125
Report Date: 07/03/2024
Date Signed: 07/09/2024 04:25:54 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/21/2024 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240321125102
FACILITY NAME:PRESTIGE ASSISTED LIVING AT MANTECAFACILITY NUMBER:
397004125
ADMINISTRATOR:EDGAR PARRAFACILITY TYPE:
740
ADDRESS:1130 EMPIRE AVE.TELEPHONE:
(209) 239-4531
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY:130CENSUS: 82DATE:
07/03/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Edgar ParraTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff not assisting residents in a timely manner.
Staff not assessing residents prior to admission.
Staff not providing residents meals in a timely manner.
Staff not keeping facility free of pests.
Facility does not have an adequate amount of staff.
INVESTIGATION FINDINGS:
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Unannounced complaint visit made out to this facility on 07/03/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Edgar Parra at this time. A brief interview was conducted with the facility designated Administrator at this time.
Current census was 82 residents, of which, 18 residents resided in the Memory Care unit of this facility which was also referred to as Expressions.
The purpose of this visit was to deliver the findings of this investigation to this facility and it's representative, Edgar Parra, at this time.
Based on a review of the documents conducted, specifically in regards to the alleged presence of pests, that were submitted into CCL, it was learned that the contracted pest control company, Ecolab Pest, has been of service to this facility for several years. It was learned from reports left by Ecolab Pest, dating back from January 1, 2024 until April 2024 stated that this facility did not have any presence of rats or cockroaches as denoted on the final statements made on the reports.
Based on a review of the documents conducted, specifically in regards to facility staffing, it was learned that
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20240321125102
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 ASSISTED LIVING AT MANTECA
FACILITY NUMBER: 397004125
VISIT DATE: 07/03/2024
NARRATIVE
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there were (3) shifts that were deployed which were then broken down into (8) hour shifts for overall care and supervision unto the residents. The AM shift (06:00 am to 02:00 pm) reported a total of 14 primary care assistants (PCAs) on the most recently updated LIC 500 dated and completed on 05/20/2024. It was observed that the PM shift (02:00 pm to 10:30 pm) reported a total of 13 primary care assistants (PCAs) on record at this time. The NOC shift (10:00 pm to 07:00 am) reported a total of 5 primary care assistants on record at this time. It was learned that these reported staff numbers for the PCAs did not include the presence of Medication Technicians (Med Techs) who were also available to assist the PCAs if needed.
It was learned that staff assisting with meal preparations, serving the meals, and delivering meals had a total of 14 staff on file at this time on the reported LIC 500. These staff members were tasked with the responsibilities to serve the residents in the dining room as well as delivering meals to the residents who chose to eat in their own rooms. It was observed that meals were served in a timely manner with seating of the residents, service of the meals, and clean up of the main dining area afterwards. This also included the deliveries of the meals unto residents on the first and second floors to make sure that they were still hot and suitable for the residents.
Based on a review of the forms and documents conducted, it was learned that this facility employed a signal system that was triggered when a resident activated their pendant, or emergency pull cord, which in turn sent a signal to the main system. This main system then sent an alert to the facility staff, on their issued mobile devices, that a resident was in need of assistance. It was learned that the room number, or location of the activated signal, would be displayed so that facility staff would know where to locate and assist the resident. It was learned that once they located the resident, staff would address the need for service and reset the pendant or pull cord only after the issue(s) had been resolved.
Based on a review of the documents conducted, it was learned that this facility employed a system that tracked resident activation time, how long it took the staff to respond to the initial call, and how long it took the facility staff to address the issue and reset the pendant or pull cord. It was learned that facility staff took an average of 15 seconds to respond to the initial signal with a maximum of 57 seconds before responding to the calls for assistance. It was learned that facility staff took an average of 3 minutes and 38 seconds to assess the needs of the resident along with the reason for the signal activation before resetting the signal system.
Based on a review of the documents conducted, it was learned that the admission process for this facility supported the presence of the resident, their representatives, and a member of this facility. It was observed that an extensive interview was conducted to ascertain the cognitive abilities, as well as, the physical abilities of the resident which were all documented on the admission packet that was performed for every possible resident.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20240321125102
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 ASSISTED LIVING AT MANTECA
FACILITY NUMBER: 397004125
VISIT DATE: 07/03/2024
NARRATIVE
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It was learned that the admission packet consisted of an assessment totaling more than twenty pages to determine acuity and proper level of care for each resident. It also consisted of an admissions agreement totaling more than twenty pages in length outlining the rules and procedures for residents while under the care and supervision of this facility. There were other forms and documents associated with this process such as the Physician's Report, Needs/Appraisal, and Level of Care which determined the overall level of care which was then used and translated to level of financial costs unto the resident and their responsible parties.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegations finding of Unsubstantiated meant that although the allegations may have happened or were valid, there was not a preponderance of the evidence to prove that the alleged violations occurred.

There were no deficiencies observed or cited during today's complaint visit at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3