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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700985
Report Date: 06/11/2021
Date Signed: 06/11/2021 02:52:40 PM

Document Has Been Signed on 06/11/2021 02:52 PM - It Cannot Be Edited

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:PRESTIGE CARE HOMES IIFACILITY NUMBER:
342700985
ADMINISTRATOR:MARINAS, MARCIALFACILITY TYPE:
740
ADDRESS:3405 HUNTSMAN DRTELEPHONE:
(916) 802-7610
CITY:SACRAMENTOSTATE: CAZIP CODE:
95826
CAPACITY: 6CENSUS: 5DATE:
06/11/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Administrator Marcial MarinasTIME COMPLETED:
03:30 PM
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On 6/11/21 at 9:00am Licensing Program Analyst (LPA) Kevin Gould conducted a pre licensing inspection for Prestige Care Homes 2. LPA Gould met with Administrator Marcial Marinas and the Licensee. There are currently five (5) residents in placement (see LIC-811, dated 4/21/21).

The Licensee is requesting a capacity of six (6) LPA observed the approved fire clearance is for six (6) residents, six (6) resident may be non-ambulatory. The home is a two story located in a residential area with 6 bedrooms, 3 bathrooms, living room, dining room, receiving room, kitchen, Staff office and break room and laundry and backyard with no pools or bodies of water.

Facility layout is as follows:
Bedroom #1: Occupied by R1, with a capacity for one (1) resident. LPA observed one bed, adequate storage and lighting. Smoke detector is working and operational. Private bathroom
Bedroom #2: Occupied by R1, with a capacity for one (1) resident. LPA observed one bed, adequate storage and lighting. Smoke detector is working and operational.
Bedroom #3: Occupied by R2, with a capacity for one (1) resident. LPA observed one bed, adequate storage and lighting. Smoke detector is working and operational.
Bedroom #4: Occupied by R3, with a capacity for one (1) resident. LPA observed one bed, adequate storage and lighting. Smoke detector is working and operational.
Bedroom #5: Occupied by R4, with a capacity for two (2) residents. LPA observed two beds, adequate storage and lighting. Smoke detector is working and operational. shared bathroom
Bedroom #6: Occupied by R5, with a capacity for one (1) resident. LPA observed one hospital style bed, adequate storage and lighting. Smoke detector is working and operational.
Bathroom #1: is a full bathroom equipped with toilet, sink and shower with appropriate grab bars.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 06/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/11/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: PRESTIGE CARE HOMES II
FACILITY NUMBER: 342700985
VISIT DATE: 06/11/2021
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Upstairs: LPA observed two overnight staff bedrooms and one staff bathroom. No resident bedrooms upstairs.

LPA observed adequate seating for residents in the kitchen and an appropriate number of plates, cups and silverware to meet the residents needs. Licensee has an appropriate supply of non-perishable food supply and a 2 day supply of fresh perishable foods. LPA observed the medication storage in the kitchen cabinet with no other food items and locked in accordance with Title 22 regulations. LPA also observed a small fridge for storing medications requiring refrigeration in the hallway with a lock and no other food items stored inside. LPA also observed sharp knives locked and inaccessible to residents and cleaning supplies locked away inaccessible to residents. The facility has a working fire extinguisher and fully stocked first aid kit located in the kitchen. Family room was observed with plenty of seating, TV and a staff desk and cabinets for files all with locks per regulations to ensure confidentiality. Laundry room with washer and dryer.

LPA observed the back yard to be free of any debris or hazards to residents in care. LPA observed plenty of seating in the backyard with a covered patio for shade. LPA also observed a storage shed in the back yard with a lock.

Facility will transport residents in a personal vehicle.

LPA observed that staff two (2) of the four (4) staff members working at the facility did not have their criminal record clearances transferred to the new facility. Administrator has documentation of criminal record clearances but has not changed the association due the facility not being licensed yet. member's criminal background checks have not yet been associated to the new facility.

The following deficiencies are cited per California Code of Regulations Title 22, see LIC 809-D

An exit interview was conducted with the licensee and a copy of this report was left at the facility. Facility is not in compliance for licensing at this time.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/11/2021 02:52 PM - It Cannot Be Edited


Created By: Kevin Gould On 06/11/2021 at 02:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PRESTIGE CARE HOMES II
FACILITY NUMBER: 342700985

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/14/2021
Section Cited
CCR
87355(e)(2)

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Criminal Record Clearance: All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement was not met as evidenced by 2 of the 4 staff
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Facility will ensure all staff criminal record clearances are associated to the facility and no longer associated with the old facility. POC due date is monday 6/14/21
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members present at the time of inspection were still associated to the old facility and the adminstrator thought they had to wait until licensed to associate. LPA confirmed that all staff present had criminal record clearances.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Kevin Gould
LICENSING EVALUATOR SIGNATURE:
DATE: 06/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2021


LIC809 (FAS) - (06/04)
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