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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206900
Report Date: 10/15/2021
Date Signed: 10/28/2021 07:05:02 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:RATANAKONE HOMEFACILITY NUMBER:
107206900
ADMINISTRATOR:RATANAKONE, KEVINFACILITY TYPE:
740
ADDRESS:2220 N. PROSPECTTELEPHONE:
(559) 287-6366
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:6CENSUS: 4DATE:
10/15/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Kevin RatanakoneTIME COMPLETED:
12:00 PM
NARRATIVE
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The following were in attendance:

Kevin Ratanakone, Licensee/ Administrator

Sergiy Pidgirny, Licensing Program Manager I
Katie Brown, Licensing Program Analyst

During this Informal Meeting the following issues were brought to the attention of the licensee:

87205 Accountability of Licensee Governing Body
87106 Operation Without a License
87202 Fire Clearance
87212 Emergency Disaster Plan
87109 Transferability of License
87405 Administrator - Qualifications and Duties
87455 Acceptance and Retention Limitations
87303 Maintenance and Operation
87555 General Food Service Requirements
87211 Reporting Requirements
87213 Finances
87506 Resident Records

The following deficiencies were observed and noted on the attached LIC 809D.
All violations that, if not corrected, will have direct and immediate risk to the health, safety or personal rights of clients in care. Appeal Rights provided.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: RATANAKONE HOME
FACILITY NUMBER: 107206900
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/18/2021
Section Cited

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87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (2)Knowledge of and ability to conform to the applicable laws, rules and regulations.
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This requirement was not met as evidenced by:
Licensee did not notify CCLD about relocation of residents to an alternative unlicensed location.

This poses an immediate health and safety risk to persons in care.
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Type B
10/29/2021
Section Cited

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87109 Transferability of License
(c) In all other instances, including a change in licensee, type of license, or location of the facility, the licensee shall notify the licensing agency and all residents receiving services, or their responsible persons, in writing as soon as possible and in all cases at least thirty (30) days prior to the effective date of that change.
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This requirement was not met as evidenced by:
Licensee did not notify CCLD of the change in type within 30 days.

This poses a potential health and safety 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: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2021
LIC809 (FAS) - (06/04)
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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: RATANAKONE HOME
FACILITY NUMBER: 107206900
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/29/2021
Section Cited

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87208 Plan of Operation (a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (1) Statement of purposes and program goals.
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This requirement was not met as evidenced by:
All 4 residents are under the age of 60. Facility is out of compiance of statement of purpose and program goals.

This poses a potential health and safety risk to residents in care.
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Type B
10/29/2021
Section Cited

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
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 (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.

This requirement was not met as evidenced by:
Licensee did not notify CCLD of a bed bug infestation.
This poses a potential health and safety 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: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: RATANAKONE HOME
FACILITY NUMBER: 107206900
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/29/2021
Section Cited

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87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
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This requirement was not met as evidenced by:
Licensee does not maintain a complete and current record for each resident in the faciliy available to staff and licensing agency staff.

This poses a potential health and safety 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: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4