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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585000698
Report Date: 11/23/2021
Date Signed: 11/23/2021 11:06:49 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:PRESTIGE ASSISTED LIVING AT MARYSVILLEFACILITY NUMBER:
585000698
ADMINISTRATOR:STRAHL, BRANDYFACILITY TYPE:
740
ADDRESS:515 HARRIS STREETTELEPHONE:
(530) 749-1786
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY:72CENSUS: 59DATE:
11/23/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:24 AM
MET WITH:Sherri BanfordTIME COMPLETED:
12:15 PM
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On 11/23/2021 at 10:15 AM, Licensing Program Analyst (LPA) Dawn Keane arrived at the facility unannounced to conduct a case closure visit. LPA met with Sherri Banford Health Services Director (HSD) and explained the purpose of the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N 95 Mask. Additional LPA was screened at the front desk upon entering the facility.

Case Closure:

Individual’s name:  Karena Brito


· Is individual working?:      no
· Comments: HSD reports that Karena is no longer working at the facility
Date confirmation received: 11/23//2021    
Date of facility visit **:      11/23/2021
Civil penalties issued?:      No
Further Action required?:      No

No deficiencies are being cited as a result of todays visit. Copy of the report given to HSD.

SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Dawn KeaneTELEPHONE: (530) 895-2660
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
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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