342700987-4-28-2025-27-AS-KVIA-DG6VCY-20250428161954

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700987
Report Date: 04/28/2025
Date Signed: 04/28/2025 04:20:05 PM

Document Has Been Signed on 04/28/2025 04:20 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 1		FACILITY NUMBER:	342700987
ADMINISTRATOR/ DIRECTOR:	VIDAN BARIAS		FACILITY TYPE:	740
ADDRESS:	9847 LINCOLN VILLAGE DRIVE		TELEPHONE:	(916) 802-7610
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95827
CAPACITY: 6		CENSUS: 3	DATE:	04/28/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:22 PM
MET WITH:	Vidan Barias		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Unannounced Annual Inspection visit was made by Licensing Program Analyst (LPA) Kimberly Viarella to this facility on 04/28/25. LPA identified herself to the Caregiver on duty, explained the purpose of the visit, and asked to speak with the Designated Facility Administrator (DFA). Staff contacted Vidan Barias and they arrived approximately 20 minutes later.

LPA noted the DFA's certificate, # 70245567490 expires on 1/27/27.

The inspection began in the kitchen. All knives and sharps were locked and inaccessible to residents in care. The food supply was adequate for 2-day perishable and 7-day nonperishable. Opened packages in the refrigerator were dated appropriately. The (3) fire extinguishers was last serviced on 11/14/24 by Jorgensen Company and were also in compliance.

LPA inspected the 6 resident bedrooms, 1 staff bedroom, 1 office, and all common areas, as well as the garage and laundry room. All resident rooms had the required furniture, furnishings and lighting to be in compliance at this time.

LPA noted soap, paper towels and trash cans with lids in the 3 bathrooms. The hot water temperature was measured at 106.3 degrees Fahrenheit and was in compliance.

The exterior of the building was inspected by the LPA. There were no bodies of water present and the yard was completely fenced in. LPA observed that all screens and gutters were in good repair. There was 1 storage shed with a lock that contained miscellaneous furniture and storage items. There was also a patio

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Kimberly Viarella
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

Page: 2 of 4

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 1	FACILITY NUMBER: 342700987
	VISIT DATE: 04/28/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

with a shaded area and furniture so the residents could enjoy the outdoors.

LPA requested the locked mini refrigerator be opened so it could be inspected. LPA observed 3 expired medications for residents who were now deceased:10 mg bisacodyl, 2 mg lorazepam, a second script for 2 mg lorazapam, along with a bottle of Pepto Bismol dated 11/2020. LPA instructed staff to dispose of these medications and LPA observed the Administrator and carestaff empty the contents of the liquid medications onto a diaper and once secured in a knotted trash bag, staff took the bag out to the trash. LPA cited for this deficiency on the LIC 809D page.

The LPA observed all other medications were stored in a large locked cabinet in the kitchen and inaccessible to residents in care. LPA observed that each resident had a clearly marked covered bin that displayed their name. LPA checked a sample of medications and all were current at the present time. LPA reviewed storage, administration and destruction procedures. A review of the First Aid kit by the LPA found it to be complete and in compliance.

A file review was completed next. LPA reviewed 2 staff files and 2 resident files. All were in compliance at the time of this inspection.

According to the California Code of Regulations, Title 22, the one deficiency observed during today's visit was cited on the LIC 809D page. A copy of this report along with APPEAL RIGHTS were provided.

Exit interview.

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Kimberly Viarella
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2025

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 04/28/2025 04:20 PM - It Cannot Be Edited

Created By: Kimberly Viarella On 04/28/2025 at 04:03 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 1	FACILITY NUMBER: 342700987
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(i)

87465(i) Incidental Medical and Dental Care (Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above when this LPA observed 3 expired prescription medications and 1 bottle of Pepto Bismol in a locked refrigerator for residents who had died. These medications were not destroyed as required. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/02/2025
	Plan of Correction
1 2 3 4	Administrator stated that they will make a check list that will include checking to ensure that the hospice nurse destroys and disposes of all medications for the deceased resident. The Administrator will email Community Care Licensing at CCLASCPSacrmentoRO@dss.ca.gov by the close of business of 05/09/25.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:

	Kimberly Viarella
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/28/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2025

LIC809 (FAS) - (06/04)

Page: 4 of 4