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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700575
Report Date: 06/28/2024
Date Signed: 07/01/2024 07:54:45 AM


Document Has Been Signed on 07/01/2024 07:54 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:A PRESTIGE LIVINGFACILITY NUMBER:
502700575
ADMINISTRATOR:SOPHIA PATTERSONFACILITY TYPE:
740
ADDRESS:3208 TEHAMA CTTELEPHONE:
(209) 284-0075
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:6CENSUS: 4DATE:
06/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Simone Pierre-JeromeTIME COMPLETED:
01:30 PM
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On 06/19/2023 at 10:00am, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct an Annual visit. LPA met with Facility Designated Administrator, Simone Pierre-Jerome and explained the purpose of this visit.
This facility is 6 elderly residents, 4 of which may be non-ambulatory and 1 bedridden. This facility also has a hospice waiver for 5 and has a dementia plan on file.
Current census was 4. A brief interview with FDA Jerome was conducted.

LPA reviewed 4 resident files. 4 out 4 resident files were complete and up to date. LPA reviewed 3 staff files. 3 out 3 staff files were current and up to date. The Facility Designated Administrator has a current and active administrator certificate #6056411940 and expires on 07/08/2024.
The tour of the physical plant was conducted. Fire extinguisher located in the kitchen was observed to be present and had a receipt of purchase was attached on 03/11/2024. Carbon monoxide detector and smoke alarms were present and observed to be in working condition.
The kitchen area was toured. LPA observed a non-perishable and perishable foods in the cabinets and refrigerator. Additional perishable food supplies were identified in the garage.
LPA observed a locked centralized stored medication cabinet located in the kitchen. Along with the administrator, the LPA observed, reviewed, and compared resident medication and medication dispensing logs.
A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees. A linen closet was located in the hallway and presented a sufficient amount of linens to adequately supply and meet the needs of the residents at this time.
A tour of the bedrooms was conducted. Resident furniture was observed to be sufficient to meet their needs at this time.
Laundry area was toured. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2024
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: A PRESTIGE LIVING
FACILITY NUMBER: 502700575
VISIT DATE: 06/28/2024
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Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.

A tour of the garage was conducted. Additional perishable food supplies were identified.

The exterior of the physical plant was toured. Perimeter fence was observed to be stable and gates were in good repair.

The following forms and documents were requested to be updated and submitted into CCL

-LIC 308

-LIC 400

-LIC 500

-LIC 610

-Liability Insurance

Based on the observations made there are no deficiencies being cited today.



Exit Interview was conducted and copy of the LIC 809, LIC 809-C, were given to the facility at the end of the visit.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2024
LIC809 (FAS) - (06/04)
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