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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700985
Report Date: 04/21/2023
Date Signed: 04/21/2023 02:26:51 PM

Document Has Been Signed on 04/21/2023 02:26 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:VIDAN BARIASFACILITY TYPE:
740
ADDRESS:3405 HUNTSMAN DRTELEPHONE:
(916) 802-7610
CITY:SACRAMENTOSTATE: CAZIP CODE:
95826
CAPACITY: 6CENSUS: 5DATE:
04/21/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Daisy LaplanaTIME COMPLETED:
02:45 PM
NARRATIVE
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On 4/21/23 at 1:45pm Licensing Program Analysts (LPAs) Kevin Gould and Brandon Panariello conducted an unannounced Case Management inspection to address concerns regarding a resident elopement that occurred on 4/1/23 and reported to the department on 4/3/23.

LPAs reviewed and obtained former resident's LIC 602, physician report dated 3/20/23 which indicates the former resident was unable to leave the facility unassisted. LPA and staff discussed the circumstances of why resident was able to leave the facility unassisted. Staff informed LPAs that resident is difficult to control and had ordered his own taxi to take him to the hospital without staff knowledge. When the taxi arrived resident got into the taxi and left the facility. Staff did attempt to stop the resident but were unable to intervene. Resident did not go to hospital and was reported missing by family. Resident returned to the facility the same day.

The following deficiencies are cited per California Code Regulation, TITLE 22.

Exit interview was conducted with the facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2023
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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Document Has Been Signed on 04/21/2023 02:26 PM - It Cannot Be Edited


Created By: Kevin Gould On 04/21/2023 at 02:04 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: 04/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/24/2023
Section Cited
HSC
1569.2(c)

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"Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking
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Facility conduct retraining for all staff who provide supervision for residents on the requirements for supervision and the plan for staff when a resident who cannot leave the facility unassisted is attempting to leave the facility without staff supervision.
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medications, money management, or personal care. This requirement was not met as evidenced by staff allowed resident to leave the facility in a taxi stating he was going to the hospital. Resident never arrived at the hospital and family reported him missing once it was discovered he was not at the hospital which poses an immediate health, safety and personal rights risk to residents in care.
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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: 04/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023


LIC809 (FAS) - (06/04)
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