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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700985
Report Date: 02/11/2025
Date Signed: 02/11/2025 11:21:15 AM

Document Has Been Signed on 02/11/2025 11:21 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:
02/11/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Vidan BariasTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on a complaint investigation. During the course of that investigation, LPA Moleski discovered other deficiencies unrelated to the complaint allegations, which will be addressed in this case management report. LPA Moleski met with facility administrator Vidan Barias and explained the purpose of the visit.

LPA Moleski reviewed a resident’s (R1’s) medication administration records (MARs) as part of the previously mentioned complaint investigation. LPA Moleski observed that dosage amounts were not recorded for multiple doses of a PRN antipsychotic and a PRN opioid narcotic. Dosages are missing for one or more administrations of one or both of these medications on 10/26, 10/27, 10/28, 10/29, 10/30, and 10/31. Per 22 CCR Section 87465(b-d), PRN medications may only be given to a resident if their physician has stated in writing their ability to determine their need for PRN medications and communicate their symptoms. If that resident has deficits in either area, then a record including dosages must be maintained for all PRN medication administrations. LPA Moleski reviewed R1’s file and did not observe any documentation from R1’s physician regarding their ability to determine their need for PRN medications and communicate their symptoms.

R1 was admitted to this facility as of 10/25/24, according to their admission agreement. However, R1’s LIC 602 examination was dated 10/31/24, after R1 was already admitted. The LIC 602 was not signed by R1’s physician until 11/1/24. Per 22 CCR Section 87458(a), medical assessments must be obtained “prior to a person’s acceptance as a resident.”

[continued on 809-C]
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2025
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: PRESTIGE CARE HOMES II
FACILITY NUMBER: 342700985
VISIT DATE: 02/11/2025
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Based on multiple interviews with staff and other witnesses, and based on review of facility records, R1 suffered from restlessness and agitation between at least 10/31/24 and their death on 11/5/24. In an interview, a staff member (S3) admitted to moving a recliner up against R1’s bed in order to prevent R1 from slipping out. In an interview, R1’s responsible party said they had also observed a wheelchair moved up against R1’s bed, and additional lower railings in order to prevent R1 from getting up out of bed.

22 CCR Section 87608(a)(1) includes among postural supports devices which are used to prevent a resident from falling out of bed. Section 87608(a)(2) states that residents must be able to release any such device quickly, and Section 87608(a)(3) states that there must be written orders for the use of any such device from the resident’s physician. Section 87608(a)(5)(B) prohibits full-length bed rails, except for residents receiving hospice care, and when their hospice care plan specifies the need for full rails. LPA Moleski reviewed R1’s hospice care plan and did not observe any indication that R1 was approved to have full rails installed on their bed.

This facility is hereby cited per 22 CCR Sections 87608(a), 87465(b), and 87458(a). 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: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/11/2025 11:21 AM - It Cannot Be Edited


Created By: Vincent Moleski On 02/11/2025 at 10:21 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: 02/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/13/2025
Section Cited
CCR
87608(a)

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87608(a): “Postural supports may be used under the following conditions … [et seq.]” This requirement was not met as evidenced by:
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Licensee agrees to conduct a staff training regarding the use of restraints. Licensee agrees to provide LPA with a training schedule by POC due date. vincent.moleski@dss.ca.gov
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Based on interview and record review, R1 was restricted from leaving their bed with devices not approved for use by their physician or hospice agency, and which did not permit quick release by the resident, which poses an immediate health, safety, and/or personal rights risk.
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Type B
02/25/2025
Section Cited
CCR87465(b)

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87465(b): “If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication.” This requirement was not met as evidenced by:
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Licensee agrees to review this Section and provide a written acknowledgement of its requirements by POC due date. vincent.moleski@dss.ca.gov
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Based on record review, R1 did not have the necessary physician’s authorization to receive assistance with PRN medications from facility staff, which poses a potential health, safety, and/or personal rights 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: 02/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/11/2025 11:21 AM - It Cannot Be Edited


Created By: Vincent Moleski On 02/11/2025 at 10:23 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: 02/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/25/2025
Section Cited
CCR
87458(a)

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87458(a): “Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.” This requirement was not met as evidenced by:
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Licensee agrees to review this Section and provide a written acknowledgement of its requirements by POC due date. vincent.moleski@dss.ca.gov
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Based on record review, R1 was examined for their medical assessment after already being admitted to this facility, which poses a potential health, safety, and/or personal rights 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: 02/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2025


LIC809 (FAS) - (06/04)
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