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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004125
Report Date: 09/06/2024
Date Signed: 09/10/2024 11:19:02 AM

Document Has Been Signed on 09/10/2024 11:19 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/
DIRECTOR:		EDGAR PARRAFACILITY TYPE:
740
ADDRESS:1130 EMPIRE AVE.TELEPHONE:
(209) 239-4531
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY: 130CENSUS: 80DATE:
09/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Edgar ParraTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Unannounced annual visit made out to this facility on 09/06/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Edgar Parra, who was briefly interviewed. Current census was 80 residents.
It was learned that there were (9) residents under the care of hospice at this time while (14) other residents were receiving services through home health as well.
This facility does have a hospice waiver approved for (15) residents and fire cleared for bedridden and dementia care for residents at any given time.
It was learned that there was only (1) deemed to be bedridden at this time.
A tour of this facility was conducted.
Administrator certificate was observed to be present for facility designated Administrator Edgar Parra. The expiration date was set for 07/29/2024. All documents have already been submitted to renew at this time.
Kitchen area was toured. Cabinets and drawers were reviewed. Food preparation stations, dishwashing station, and other areas intended for meal preps were toured.
Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. This LPA did observe additional food storage units which were present and functional at this time.
A tour of the dining area, living area, and all other areas intended for resident use was conducted.
Medication rooms, located on each floor, were reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications were discussed with the facility designated medication technicians at this time. The medication carts were observed to be locked and made inaccessible to the residents at this time.
A tour of the resident bedrooms and restroom was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. It was learned that there were (3) different floor plans for residents on the Assisted Living portion of this facility.
Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2024
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 ASSISTED LIVING AT MANTECA
FACILITY NUMBER: 397004125
VISIT DATE: 09/06/2024
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Linen closet, located in the facility laundry area, was observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time.
A tour of the Memory Care portion, Expressions, was conducted.
Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 08/12/2024 by the local fire extinguisher company, Jorgensen Co., and in compliance at this time.
First aid kits were observed to be present and contained all of the required components at this time.
Exterior grounds of this facility were toured.
A review of the facility perimeter fence, side gates, and exits was conducted.

A review of (7) facility resident files was conducted.
A review of (6) facility personnel files was conducted.

The following forms and documents were requested to be updated and submitted into CCL:
  • LIC 308

  • LIC 400

  • LIC 500

  • LIC 610


There were no deficiencies observed or cited during today's annual visit.

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

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC809 (FAS) - (06/04)
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