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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507003973
Report Date: 11/13/2020
Date Signed: 11/13/2020 12:41:00 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/10/2020 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20201110103222
FACILITY NAME:PRATHNA RESIDENTIAL CARE FACILITY FOR THE ELDERLYFACILITY NUMBER:
507003973
ADMINISTRATOR:PRASAD, MUKESHFACILITY TYPE:
740
ADDRESS:3708 CARLISLE COURTTELEPHONE:
(209) 577-2133
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:5CENSUS: 4DATE:
11/13/2020
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Mukesh PrasadTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff are not properly reporting incidents as required.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Avelina Martinez contacted the facility via telephone to commence a complaint investigation via telephone on 11/13/2020 due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call and the elements of the allegation with Mukesh Prasad.

Throughout the investigation, LPA Martinez reviewed Community Care Licensing (CCL) received SIR reports. LPA Martinez determined a SIR report was not received for R1's incident on 10/28/20020. The facility did not ensure to submit an SIR report for incident 10/28/2020.

As a result of this investigation, the Department finds this allegation to be substantiated. An exit interview was conducted with Mukesh Prasad. A copy of this report was provided to Mukesh Prasad via email and an electronic email read receipt confirms receiving these documents. The following deficiency was cited, per Title 22 Regulations, The deficiency cited can be found on 809-D, and appeals rights given to the facility.
Substantiated
Estimated Days of Completion: 90
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2020
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 2
Control Number 27-AS-20201110103222
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PRATHNA RESIDENTIAL CARE FACILITY FOR THE ELDERLY
FACILITY NUMBER: 507003973
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/27/2020
Section Cited
CCR
87211(a)(1)
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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted to the licensing agency...within seven days...
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Licensee agrees to review Reporting 87211 regulation, and conduct a in-services training on reporting for all staff.
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This regulation is not met as evidenced by: Based on interview and records review the licensee did not ensure to report to CCL. This posed a potential health and safety risk to residents in care.
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Licensee agrees to email LPA Martinez in-service training materials; and review regulation statement; and training sign in sheet by POC Date 11/27/2020.
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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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2