<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005433
Report Date: 08/01/2023
Date Signed: 08/18/2023 11:01:58 AM


Document Has Been Signed on 08/18/2023 11:01 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/17/2023 03:31 PM

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

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
This is an amendment document for the visit on 8/1/2023. Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived at this facility unannounced at 10am to conduct an annual required inspection. During that visit, LPAs met with Staff2 (S2) Maria Elena Puso Atienza and explained the purpose of the visit. Administrator is currently unavailable for this inspection due to family emergency.

LPAs observed that the roof has been repaired. LIC200 and permit for the roof repair has been received by the Department. LPAs observed that the garage is currently undergoing construction. As per staff on duty, the licensee is in the process of converting the garage with two additional bedrooms. LPAs inspected the garage and observed the construction is for two additional bedrooms. The emergency exit in the garage remains unchanged and observed to be unobstructed.

Based on record and interview, Staff1 (S1) on duty is not cleared to work at this facility and observed by LPAs to be left alone with residents in care. Due to Administrator's family emergency, this annual inspection was not able to be completed. LPAs will return at a later date for completion. LPAs requested updated copies of LIC 200, current and proposed facility sketch reflecting the garage conversion, building permit, LIC 308, LIC 500, and resident roster. LPAs requested from licensee to submit a plan to ensure residents' rights and their health and safety during construction to the Department by 8/4/2023.

Note: This is an amendment document for the visit on 8/1/23. LPAs met with staff on duty, Gyaneshawari Verma, and explained the purpose of the visit. Licensee arrived shortly after and informed LPAs that Gyaneshwari can sign on the Licensee's behalf.

Citation are issued under Title 22, Division 6. An immediate civil penalty in the amount of $200 is issued in addition to citation. An exit interview was conducted with Gyaneshawari Verma and a copy of this report and appeal rights were provided to Gyaneshawari.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2023
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 2


Document Has Been Signed on 08/18/2023 11:03 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/11/2023 09:52 AM

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: 08/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/02/2023
Section Cited
CCR
87411(g)(1)

1
2
3
4
5
6
7
87411 Personnel Requirement (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations.
1
2
3
4
5
6
7
Licensee to read regulation 87411(g)(1) and submit a signed declaration of understanding to LPA by POC due date.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: The license did not ensure S1 was cleared prior to working with residents.
8
9
10
11
12
13
14
S1 will be taken out of the schedule until until fingerprint clearance is approved. Licensee to submit clearance to the Department once approved.
Type B
08/04/2023
Section Cited
CCR87208(a)(7)(A)

1
2
3
4
5
6
7
87208. Plan of Operation...(a)Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval...(7) Sketches, showing dimensions, of the following: (A)Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended and a designation of the rooms to be used for nonambulatory residents and for bedridden residents. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee to submit LIC 200, current and proposed facility sketch reflecting the garage conversion, and building permit to the Department by POC due date.
8
9
10
11
12
13
14
The licensee did not submit LIC 200 and current and proposed facility sketch reflecting the garage conversion to the Department prior to construction.
8
9
10
11
12
13
14
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: Liza KingTELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2