<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700575
Report Date: 01/11/2022
Date Signed: 01/11/2022 12:34:24 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:
01/11/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:59 AM
MET WITH:Patterson, SophiaTIME COMPLETED:
12:00 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
LPA Johnson arrived to the facility unannounced to conduct a Case management incident/ Inspection related to a call to the department on 1/6/2022.

SIR, details R1 AWOL from the facility on 1/06/2022. R1 was in an agitated state and staff attempted to utilize verbal redirection and other strategies to calm resident down. Resident went to his room and shut the door. After a phone call from R1's daughter staff went to check on R1. Staff noticed that R1 had left facility. Facility Staff called 911 and notified the licensee.

R1 was found by a neighbor and transported by AMR (American Medical Response)to Memorial hospital. R1 has not returned to the facility at the request of his daughter.

LPA reviewed R1 facility file, physician's report reveals that resident has been determined to be able leave facility unassisted without staff supervision. As a result of this incident, and review of pertinent documentation, No deficiencies were cited on today's date.

LPA was able to obtained copies of resident's functional assessment (pre-assessment) service plan and other pertinent information from R1's last placement. Exit interview conducted.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1