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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507003973
Report Date: 09/20/2021
Date Signed: 09/22/2021 11:50:19 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 ELDERLYFACILITY NUMBER:
507003973
ADMINISTRATOR:PRASAD, MUKESHFACILITY TYPE:
740
ADDRESS:3708 CARLISLE COURTTELEPHONE:
(209) 577-2133
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:5CENSUS: 4DATE:
09/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Venorma PrasadTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facilities annual inspection. LPA met with Licensee Venorma Prasad. Continual Administrator's Certification expires 12/21/2021. There are currently 4 residents who reside at this home. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair.

Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 108.9 F degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible.

The following deficiencies were cited during today's inspection per California Code of Regulations, Title 22.

LPA's requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with Administrator and copy of report left at facility
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/20/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(26)
(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 has not been met as evidenced by

This requirement is not met as evidenced by:
Deficient Practice Statement
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 Based on observation, the licensee did not ensure enough food supplies were maintained on the premises. From the LPA's observation it appears the facility does not have the necessary food requirements of (2) Day perishable and (7) Day Non-perishable food supply.
POC Due Date: 09/27/2021
Plan of Correction
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Licensee will submit receipts to LPA by POC date.
Type A
Section Cited
CCR
80020(a)
Fire Clearance. All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation of fire extinguisher in the kitchen, the date of inspection on the tag is labeled 09/04/2019. The extinguisher is due for its annual inspection, this poses a potential health and safety risk to the residents in care.
POC Due Date: 09/21/2021
Plan of Correction
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LPA will conduct POC visit to observe correction.
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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2021
LIC809 (FAS) - (06/04)
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