107206900-11-3-2021-24-AS-KBRN-C8EU5E-20211103151638

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107206900
Report Date: 11/03/2021
Date Signed: 11/03/2021 03:16:49 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 HOME		FACILITY NUMBER:	107206900
ADMINISTRATOR:	RATANAKONE, KEVIN		FACILITY TYPE:	740
ADDRESS:	2220 N. PROSPECT		TELEPHONE:	(559) 287-6366
CITY:	FRESNO	STATE: CA	ZIP CODE:	93722
CAPACITY:	6	CENSUS: 4	DATE:	11/03/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Kevin Ratanakone AKA Dean Murphy		TIME 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	Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct the Infection Control Annual visit. LPA met with caregiver Amritbir Dhillon who informed Administrator, Kevin Ratanakone (AKA Dean Murphy) of the visit. Administrator arrived shortly to meet with LPA. Licensee has not submitted a Mitigation Plan (LIC 808). LPA toured the facility inside and out with Administrator. LPA observed the following related to infection control: There is no Covid screening area for visitors or staff and resident screening is not being conducted. Sanitizer and disposable masks are available for use and signs are posted throughout the facility. LPA reviewed infection control procedures according to the Mitigation Plan with Administrator. During the facility tour, LPA observed the following: There is no furniture in resident rooms other then beds. There were no linens on the beds and LPA did not see extra linens available. Resident bedroom, garage and kitchen windows do not have a screen. The garage is used to store furniture, LPA observed multiple garbage bags full of clothes stacked up, a bowl of food and empty food containers. In the living room, window blinds are broken and food containers containing old food and ants. Ants were also observed in the kitchen refrigerator and on counter tops. The facility does not have 7 days nonperishable food. LPA requested to review Personnel files which Administrator reported are not kept at the facility. LPA requested to review the resident files. On 10/28/21 LPA received a statement from the Administrator that resident files were complete and available in the facility as a POC. The files were reviewed and observed to be incomplete. LPA provided LIC311F. Civil Penalty assessed today. The following forms requested to be updated and submitted to LPA: LIC 308, 309 610E, 500, 9020, a copy of current Liability Insurance and Mitigation Plan. Submit to LPA by 11/17/21. A copy of this report, Appeal Rights have been provided to Administrator. Exit interview conducted. See 809-D for deficiencies.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie Brown	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021

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: 11/03/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(g)

87412 Personnel Records (g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. This requirement is not met as evidenced by: Licensee does not maintain the personnel files at the facility. The files are not availble for review.
	Deficient Practice Statement
1 2 3 4	Based on interview the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/17/2021
	Plan of Correction
1 2 3 4	Licensee will provide a written statement that states that the personnel files are complete and available for review to CCLD via email by 11/17/2021.

Type B

Section Cited

CCR

87307(3)

87307 Personal Accommodations and Services (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: 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. The required bedroom furniture has not been provided too R1, R2, R3 or R4. Required bed linens have not been provided for R1, R2, R3 or R4. which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/08/2021
	Plan of Correction
1 2 3 4	Licensee will provide proof of placement or purchase of required bedroom furnishings and bed linens including blankets to CCLD by 11/8/2021.

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 Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie Brown	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021

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: 11/03/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(26)

87555 General Food Service Requirements (b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. During the facility tour, LPA observed that there is not 7 days of perishable food available at the facility.
	POC Due Date: 11/17/2021
	Plan of Correction
1 2 3 4	Licensee will provide proof or purchase of 7 days of perishable food available at the faciliity to CCLD by 11/17/2021.

Type B

Section Cited

CCR

87555(b)(27)

87555 General Food Service Requirements (b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. During the facility tour, LPA observed ants in the refrigerator, the counter tops and in food containers.
	POC Due Date: 11/17/2021
	Plan of Correction
1 2 3 4	Licensee will provide proof of Pest Control services at the facility to CCLD by 10/17/2021.

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 Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie Brown	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021

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: 11/03/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care. LPA Observed broken blinds in the living room, open food containers throughout the home and missing window screens (bedroom, garage and kitchen).
	POC Due Date: 11/17/2021
	Plan of Correction
1 2 3 4	Licensee will provide proof of replaced window screens. Licensee will remove the broken blinds. Licensee will provide proof of a plan to ensure food containers are thrown away same day or after food is eaten. proof of these will be provided to CCLD by 11/17/2021.

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.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie Brown	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021

LIC809 (FAS) - (06/04)

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