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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206900
Report Date: 12/13/2021
Date Signed: 12/13/2021 12:27:01 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/08/2021 and conducted by Evaluator Katie Brown
COMPLAINT CONTROL NUMBER: 24-AS-20211008104640
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:
12/13/2021
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Dean MurphyTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff are not meeting residents care needs
Staff are not providing adequate food service
Facility has bed bugs
Facility has no staff present
INVESTIGATION FINDINGS:
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Licencing Program Analyst (LPA) Katie Brown met with Administrator to deliver the investigation findings. LPA explained the purpose of the meeting and reviewed the elements of the allegations.

The Department investigated the allegation: Staff are not meeting residents care needs. The Department obtained a Police Report which noted that based on the unsanitary condition of the house and that residents that were unable to care for themselves were left unsupervised the responding Police Officer had to physically remove residents from the home to be evaluated at the hospital. The Department also obtained the Ambulance reports which note unsafe and unsanitary living conditions. Based on interviews and record review the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED.

See 9099-C for continuation
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 24-AS-20211008104640
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 12/13/2021
NARRATIVE
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The Department investigated the allegation: Staff are not providing adequate food service. The Department was provided pictures of unsanitary food conditions at the home. A Police Report was obtained and noted foul odor, rotten food, old open food containers and roaches observed in the kitchen. Based on interview, photos provided, and record review the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED.

The Department investigated the allegation: Facility has bed bugs. The Department obtained the Ambulance report which notes that bed bugs were observed on the gurney used by the residents. During interview, the Administrator stated that the resident mattresses were removed from resident rooms and thrown out due to bed bug infestation at the home. Based on interview and record review the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED.

The Department investigated the allegation: Facility has no staff present. The Department obtained the police report which notes that upon arrival to the facility, a resident answered the door and stated that there were no staff members at the home. While EMS and Police were present at the home, a staff member arrived at the home and admitted to leaving the residents unattended. Based on interview and record review the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED.

See 9099-D for Deficiencies cited.
See LIC 421IM for Immediate Civil Penalty assessed

A copy of this report, Appeal Rights and an exit interview were conducted with Dean Murphy.

SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 24-AS-20211008104640
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/14/2021
Section Cited
HSC
1548(c)(3)
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ยง1548 Civil penalties; regulations setting forth appeal procedures for deficiencies
(c) The department shall assess an immediate civil penalty of five hundred dollars ($500) per violation and one hundred dollars ($100) for each day the violation continues after citation for any of the following serious violations:
(3) Absence of supervision, as required by statute or regulation.

This requirement was not met as evidenced by:
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Licensee has agreed to provide a written statement to CCLD which will include that the regulation has been reviewed and is understood. The statement will include measures that have been put in place to prevent the incident from happening again. This statement will be provided to CCLD by 5PM 12/14/21

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Licensee did not provide care and supervision for the residents in care. On 10/7/21 residents were found to be at the facility alone.

This poses an immediate health and safety risk to residents in care.
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Type A
12/14/2021
Section Cited
CCR
87464(D)
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87464 Basic Services
(d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources.

This requirement was not met as evidenced by:
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Licensee has agreed to provide a written statement to CCLD which will include that the regulation has been reviewed and is understood. The statement will include measures that have been put in place to prevent the incident from happening again. This statement will be provided to CCLD by 5PM 12/14/21

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Licensee did not meet residents care needs and the Police and EMS relocated the residents to the hospital for assessment on 10/7/21.

This poses an immediate 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: 12/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 24-AS-20211008104640
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/14/2021
Section Cited
CCR
87555(b)(27)
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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 was not met as evidenced by:
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Licensee did not ensure that the kitchen was clean, free of odor and insects on 10/7/21.

This poses an immediate health and safety risk to residents in care.
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Type B
12/20/2021
Section Cited
CCR
87303(a)
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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 was not met as evidenced by:

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Licensee did not ensure the facility was free of insects including Bed Bugs which were observed on the residents and the ambulance gurney.

This poses a potential health and safety risk to persons 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: 12/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4