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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700985
Report Date: 11/12/2024
Date Signed: 11/12/2024 11:39:11 AM

Document Has Been Signed on 11/12/2024 11:39 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 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: 5DATE:
11/12/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Vidan BariasTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to open a complaint investigation. During the course of the investigation, LPAs Moleski and Williams observed unrelated deficiencies. LPAs Moleski and Williams met with facility administrator Vidan Barias and explained the purpose of the visit.

Upon arrival to this facility, LPAs Moleski and Williams observed a paper bag located next to the dining room table with a sign on it which read "old meds." Inside the bag were many bottles of medications, which were out and accessible to residents in care. Additionally, located immediately next to the table on a cabinet were a bottle full of stool softener pills and a daily pill dispenser, containing approximately four weeks' worth of pills. A staff member (S1) said the daily pill dispenser was theirs.

While reviewing a resident's file (R1), LPA Moleski observed that R1 was bedridden, according to two LIC 602s, dated 10/17/24 and 10/31/24. This facility's fire clearance does not permit the acceptance or retention of bedridden residents.

While touring this facility, LPA observed a laundry room left open and unlocked which contained laundry detergent, insecticide, and two pairs of garden shears. A cabinet inside the laundry room was also left unlocked, and it contained a bleach cleaning solution.

This facility is hereby cited per 22 CCR Sections 87465(h)(2), 87202(a)(2), and 87309(a). An immediate civil penalty in the amount of $500 is hereby assessed due to a violation of fire clearance. This facility was previously cited per Sections 87465(h)(2) and 87309(a) during an annual inspection on 7/2/24. As these are repeat violations, civil penalties in the amount of $250 for each citation are hereby assessed, for a grand total of $1,000 between all three civil penalties. An exit interview was held with Barias. Appeal rights and a copy of this report were left with Barias.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2024
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 11/12/2024 11:39 AM - It Cannot Be Edited


Created By: Vincent Moleski On 11/12/2024 at 10:28 AM
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: 11/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/13/2024
Section Cited
CCR
87202(a)(2)

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"(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance ... (2) Bedridden persons." This requirement was not met as evidenced by:
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Licensee agrees to submit a written statement acknowledging fire clearance requirements and affirming that they will be adhered to in the future. Licensee said they will provide this by Friday.
vincent.moleski@dss.ca.gov
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Based on record review, the licensee admitted and retained a bedridden resident, which poses an immediate health and safety risk.
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Type A
11/13/2024
Section Cited
CCR87465(h)(2)

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"(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 was not met as evidenced by:
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Licensee agrees to conduct a staff training by Friday and will provide LPA Moleski with a sign-in sheet afterward.
vincent.moleski@dss.ca.gov
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Based on observation, the licensee left medications out unlocked and accessible to residents in care, which poses an immediate health and safety risk.
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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: 11/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/12/2024 11:39 AM - It Cannot Be Edited


Created By: Vincent Moleski On 11/12/2024 at 10:34 AM
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: 11/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/13/2024
Section Cited
CCR
87309(a)

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"(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 was not met as evidenced by:
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Licensee agrees to conduct a staff training by Friday and will provide LPA Moleski with a sign-in sheet afterward.
vincent.moleski@dss.ca.gov
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Based on observation, cleaning solutions, insecticide, and shears were left unlocked and accessible to residents in care, which poses an immediate health and safety risk.
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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: 11/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2024


LIC809 (FAS) - (06/04)
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