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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004125
Report Date: 07/03/2024
Date Signed: 07/05/2024 02:06:21 PM

Document Has Been Signed on 07/05/2024 02:06 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 ASSISTED LIVING AT MANTECAFACILITY NUMBER:
397004125
ADMINISTRATOR/
DIRECTOR:		EDGAR PARRAFACILITY TYPE:
740
ADDRESS:1130 EMPIRE AVE.TELEPHONE:
(209) 239-4531
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY: 130CENSUS: 82DATE:
07/03/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Edgar ParraTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Unannounced case management 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 follow up on a recent incident involving two residents, R1 and R2, who were both residing in the Expressions portion of this facility. It was reported that an altercation took place between the 2 residents.
This LPA was present today to review the steps that this facility took to address this matter and what the current situation was between these 2 residents and their responsible parties at this time.

There were no deficiencies observed or cited during today's case management 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
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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