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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 11:19:24 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:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Edgar ParraTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Unannounced Case Management visit made out to this facility 09/06/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Edgar Parra who was briefly interviewed at this time.
Current census was 80 residents.
The purpose of this visit was to follow up on the most recent Special Incident Reports (SIRs) submitted from this facility in regards to resident care and supervision.
A review of the SIRs submitted was conducted in regards to multiple falls, frequency of falls, and recent deaths with the facility designated Administrator at this time.

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