397004125-9-26-2023-27-AS-CYAG-CW2PR5-20230926113211

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397004125
Report Date: 09/21/2023
Date Signed: 09/26/2023 11:32:17 AM

Document Has Been Signed on 09/26/2023 11:32 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	PRESTIGE ASSISTED LIVING AT MANTECA		FACILITY NUMBER:	397004125
ADMINISTRATOR:	EDGAR PARRA		FACILITY TYPE:	740
ADDRESS:	1130 EMPIRE AVE.		TELEPHONE:	(209) 239-4531
CITY:	MANTECA	STATE: CA	ZIP CODE:	95336
CAPACITY:	130	CENSUS: 94	DATE:	09/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Edgar Parra		TIME COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Unannounced annual visit made out to this facility on 09/21/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Edgar Parra, who was briefly interviewed. It was learned that there were residents under the care of hospice at this time while other residents were receiving services through home health as well. This facility does have a hospice waiver approved for (10) residents and fire cleared for bedridden and dementia care for residents at any given time. It was learned that there weren't any residents deemed to be bedridden at this time. Current census was 94 residents. A tour of this facility was conducted alongside the facility designated Administrator Edgar Parra. Administrator certificate was observed to be present and in compliance at this time for facility designated Administrator Edgar Parra. The expiration date was set for 07/29/2024. 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.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PRESTIGE ASSISTED LIVING AT MANTECA	FACILITY NUMBER: 397004125
	VISIT DATE: 09/21/2023

NARRATIVE

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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 08/30/2023 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 (5) facility resident files was conducted.
A review of (5) 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

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal Rights were printed and a copy was given to the facility designated Administrator at this time.

Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/26/2023 11:32 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PRESTIGE ASSISTED LIVING AT MANTECA	FACILITY NUMBER: 397004125
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) 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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in [1] out of [5] facility personnel files did not contain the required initial/annual training requirements which posed an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/28/2023
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that all staff providing care and supervision to the residents will be properly trained to meet the required number of initial and annual hours. A statement of correction will be completed, along with documents to support the completion of the required hours notating trainer, topics of training, and attendees to be submitted into CCL by the due date.

Type A

Section Cited

CCR

87411(c)(1)

Personnel Requirements - General

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in [3] out of [5] facility personnel files did not contain the required first aid training requirements which posed an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/28/2023
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that all staff providing care and supervision to the residents will be properly trained and obtain first aid certification. A statement of correction will be completed, along with documents to support the completion of the first aid course notating attendees with current certification to be submitted into CCL by the due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

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