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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700985
Report Date: 07/02/2024
Date Signed: 07/02/2024 03:49:42 PM

Document Has Been Signed on 07/02/2024 03:49 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:PRESTIGE CARE HOMES IIFACILITY NUMBER:
342700985
ADMINISTRATOR/
DIRECTOR:		VIDAN BARIASFACILITY TYPE:
740
ADDRESS:3405 HUNTSMAN DRTELEPHONE:
(916) 802-7610
CITY:SACRAMENTOSTATE: CAZIP CODE:
95826
CAPACITY: 6CENSUS: 4DATE:
07/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Vidan BariasTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski and Investigator (Inv.) Tim Balarie arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Vidan Barias and explained the purpose of the visit.

LPA Moleski reviewed four resident files (R1-R4) and three staff files (S1-S3). LPA Moleski observed that R2 has a foley catheter, according to an appraisal dated 3/30/24. LPA Moleski did not observe the required record of care for a restricted health condition. Barias could not provide a record of care regarding R2's foley catheter.

LPA Moleski toured the facility with Barias and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 70 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 106 degrees Fahrenheit, which is within the required range of 105 and 120 degrees.

LPA Moleski observed fully-charged and up-to-date fire extinguishers and carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food.

LPA Moleski, Inv. Balarie, and Barias observed a resident (R2) who had medications unsecured in their room. LPA Moleski, Inv. Balarie, and Barias observed multiple cleaning solutions left unlocked in the laundry room. LPA Moleski and Inv. Balarie observed cleaning solutions under the sink in an unlocked cabinet in a resident bathroom. LPA Moleski interviewed two staff members (S1-S2) and two residents (R1-R2).This facility is being cited per 22 CCR Sections 87465(h)(2), 87309(a), and 87611(b). An exit interview was held with Barias. Appeal rights and a copy of this report was left with Barias.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024
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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Document Has Been Signed on 07/02/2024 03:49 PM - It Cannot Be Edited


Created By: Vincent Moleski On 07/02/2024 at 02:13 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PRESTIGE CARE HOMES II
FACILITY NUMBER: 342700985

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87611(b)
"(b) The licensee shall complete and maintain a current, written record of care for each resident that includes, but is not limited to, the following:"

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not maintain a record of care with all required components for R2's foley catheter, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2024
Plan of Correction
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Licensee agrees to acquire the required documentation and will provide LPA Moleski with the documents by POC due date.
vincent.moleski@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/02/2024 03:49 PM - It Cannot Be Edited


Created By: Vincent Moleski On 07/02/2024 at 03:33 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PRESTIGE CARE HOMES II
FACILITY NUMBER: 342700985

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, cleaning solutions and detergents were left unlocked and unsecured, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2024
Plan of Correction
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Licensee agrees to lock up all cleaning solutions and to provide LPA Moleski with a photograph of their new locked storage location.
vincent.moleski@dss.ca.gov
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, medications were not locked up and kept inaccessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2024
Plan of Correction
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Licensee agrees to lock up all medications and provide LPA Moleski a photograph of their new locked storage location.
vincent.moleski@dss.ca.gov
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:Stephen Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024


LIC809 (FAS) - (06/04)
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