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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002995
Report Date: 01/24/2024
Date Signed: 01/24/2024 10:47:30 AM

Document Has Been Signed on 01/24/2024 10:47 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:PRESTIGE ENVIRONS FOR THE AGESFACILITY NUMBER:
315002995
ADMINISTRATOR:HEARD, TERESITAFACILITY TYPE:
740
ADDRESS:5350 NORTHCLIFF DRIVETELEPHONE:
(916) 625-1012
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY: 6CENSUS: 3DATE:
01/24/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Administrator: Teresita Heard TIME COMPLETED:
11:00 AM
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On 01/24/2024, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility to conduct a Pre-Licensing Inspection. LPA met with Administrator, Teresita Heard, and explained the purpose of the visit.
LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed at 112 degrees F.

LPA checked the kitchen area for the ability to prepare and store food. LPA observed at least a 2-day perishable and 7-day nonperishable food supply on hand. LPA observed sharps/ knives to be locked away and inaccessible to residents in care. LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents.

LPA observed the perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards. The care home has smoke detectors and carbon monoxide detectors that are operable. Licensing complaint poster are posted as required. Fire extinguishers was last serviced on 01/06/2023. First aid kit are maintained and ready for emergency use.

Component III presentation conducted with administrator.

LPA observed that the facility is ready to be licensed. This report will be submitted to the Central Applications Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

Exit Interview conducted and copy of report provided.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Sarena Keosavang
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2024
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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