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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004125
Report Date: 12/20/2023
Date Signed: 12/22/2023 10:01:20 AM

Document Has Been Signed on 12/22/2023 10:01 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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: 89DATE:
12/20/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Edgar ParraTIME COMPLETED:
05:00 PM
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Unannounced Plan of Correction visit made out to this facility on 12/20/2023 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 89 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 follow up with the deficiencies that were originally cited on a prior visit, Annual visit, conducted on 09/21/2023:

In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

The Plan of Correction was reviewed and clearance letter was printed and a copy was given to the facility designated Administrator at this time.

No other deficiencies were observed or cited at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2023
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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