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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700985
Report Date: 06/15/2021
Date Signed: 06/15/2021 10:30:56 AM

Document Has Been Signed on 06/15/2021 10:30 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
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:
06/15/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Marcial MarinasTIME COMPLETED:
10:30 AM
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On 6/15/21 Licensing Program Analyst (LPA) Kevin Gould conducted a component III pre licensing meeting with Administrator Marcial Marinas and the Licensee . LPA Gould, Administrator and Licensee went over the component 3 powerepoint.

LPA Gould discussed Operating Requirements, Physical Environment, Personnel Requirements, Resident Records, Health Related Services and Conditions and Dementia Care.

LPA discussed the department's and LPA's responsibilities and the responsibilities of the Administrator and reporting requirements including but not limited to the forms required for reporting and documenting any changes in resident files.

Exit interview was conducted. Once approved, a copy of the license will be set to the Licensee.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2021
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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