347005433-8-18-2023-27-AS-AVIA-CUTS2X-20230818133015

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347005433
Report Date: 08/18/2023
Date Signed: 08/18/2023 01:30:24 PM

Document Has Been Signed on 08/18/2023 01:30 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:	PRASAD'S CARE HOME		FACILITY NUMBER:	347005433
ADMINISTRATOR:	SANJEETA PRASAD		FACILITY TYPE:	740
ADDRESS:	4250 ARCHEAN WAY		TELEPHONE:	(916) 431-7132
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95823
CAPACITY:	6	CENSUS: 5	DATE:	08/18/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Gyaneshwari Verma		TIME COMPLETED:	01:30 PM

NARRATIVE

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On 8/18/2023, at 10am, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva conducted an unannounced Case Management – Annual Continuation visit to continue the Annual visit initiated on 8/1/2023. LPA met with staff on duty Gyaneshwari Verma. Administrator joined shortly thereafter but had to leave due to personal matter. LPAs explained the purpose of the visit.

LPAs and staff on duty toured the facility and grounds including, but not limited to, bedrooms, bathrooms, kitchen, common area and backyard. No accessible bodies of water or fire safety hazards observed. This is a single-story home with 3 resident bedrooms and 2 bathrooms. LPAs observed the living room and dining room to be clean and free from any tripping hazards. Facility has appropriate internet access available for resident use. A comfortable temperature of 75 degrees F is maintained inside the facility, and lighting is sufficient for safety and comfort of the residents and staff. During the visit, there were 5 residents present and 1 staff on duty.

LPA toured the resident rooms and observed all 3 resident rooms to be shared rooms. LPA observed 2 full bathrooms to be equipped with liquid soap, paper towels, grab bars, non-skid mats, and a trash can with a fitted lid. The bathrooms were in good repair. The hot water temperature in the residents’ shared bathroom was measured between 105- and 120-degree F. LPA observed the facility has food supplies consisting of 2-day perishable and 7-day non-perishable. Sharps and medications were observed to be locked and inaccessible to residents. First aid kit was observed to have adequate supplies and accessible to staff. LPAs toured the garage and a washer and dryer and extra food supplies in the freezer. The garage is in the process of being converted into 2 additional bedrooms.

{Continue to LIC809-C}

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin Villanueva	TELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

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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Document Has Been Signed on 08/18/2023 01:30 PM - It Cannot Be Edited

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: PRASAD'S CARE HOME	FACILITY NUMBER: 347005433
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 out of 3 staff members which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/25/2023
	Plan of Correction
1 2 3 4	Licensee to submit a copy of completed staff CPR/First Aid to the Department by the POC due date.

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: Stephen Richardson	TELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin Villanueva	TELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

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: PRASAD'S CARE HOME	FACILITY NUMBER: 347005433
	VISIT DATE: 08/18/2023

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{Continue from LIC809}

All staff noted on LIC 500 contained criminal background clearances. LPA completed 1 staff interview. LPA observed personal rights poster.LPA reviewed the facility’s disaster plan to ensure regulatory compliance. Updated copy of LIC 308 and LIC 500, and current liability insurance were requested by LPAs to be sent to the Department..

Based on observation, interviews, and record reviews, LPAs observed 2 staff having their first aid/CPR expired. LPAs reviewed 5 residents charts and 3 staff charts.

Per California Code of Regulations, Title 22, deficiencies were observed during this visit. Exit interview was held and a report was given to staff on duty, Gyaneshwari Verma.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin Villanueva	TELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

LIC809 (FAS) - (06/04)

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