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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700575
Report Date: 06/14/2021
Date Signed: 06/14/2021 03:45:51 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:A PRESTIGE LIVINGFACILITY NUMBER:
502700575
ADMINISTRATOR:PIERRE-JEROME,SIMONEFACILITY TYPE:
740
ADDRESS:3208 TEHAMA CTTELEPHONE:
(209) 284-0075
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:6CENSUS: 6DATE:
06/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:SIMONE PIERRE-JEROME, AdministratorTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Arlene Garcia and (LPM) Stephenie Daub conducted an unannounced annual / Infection Control visit on this date. LPA and LPM greeted by Sophia Patterson, Caregiver. LPA and LPM met with Simone Pierre-Jerome, Administrator.

LPA and administrator inspected physical plant including but not limited to the main kitchen, residents bedrooms and bathrooms, and dining room areas. LPA observed sufficient 7 days non-perishable and 2 days perishable food supplies.. Hot water temperature measured at 112 degrees in residents bathroom with the AD which is in required range of 105 to 120 degrees. Last Fire Drill conduced dated 1/8//21. Fire extinguisher maintained, Fire alarm and carbon monoxide functional. LPA and administrator observed centrally stored medications. LPA reviewed staff and resident files. LPA observed resident emergency contact complete but dated 2020. Technical Advisory to notate as current dated 2021. LPA observed resident practicing social distancing. LPA observed sharps and toxins locked. LPA observed proper signage posted..

Per California Code of Regulations, Title 22 Division 6, Chapter 8, NO deficiencies are being cited today in violation of California Code of Regulations. Exit interview held with Simone Pierre-Jerome and a copy of report given at the conclusion of the visit to administrator.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2021
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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