507003973-10-26-2023-27-AS-MJEN-CWYQXB-20231026123317

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507003973
Report Date: 10/26/2023
Date Signed: 10/26/2023 12:33:30 PM

Document Has Been Signed on 10/26/2023 12:33 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:	PRATHNA RESIDENTIAL CARE FACILITY FOR THE ELDERLY		FACILITY NUMBER:	507003973
ADMINISTRATOR:	PRASAD, MUKESH		FACILITY TYPE:	740
ADDRESS:	3708 CARLISLE COURT		TELEPHONE:	(209) 577-2133
CITY:	MODESTO	STATE: CA	ZIP CODE:	95356
CAPACITY:	5	CENSUS: 4	DATE:	10/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Shirley Tudence		TIME COMPLETED:	12:45 PM

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	On 10/26/23 at approximately 9:40am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual inspection. LPA Jensen met with Administrator Shirley Tudence and explained the purpose of today's visit. The administrator holds current certificate # 6057838740 good through 11/9/2024. The current facility census is 4. The facility's plan of operation allows for care of residents with dementia. The fire clearance allows for a capacity of 5 non-ambulatory residents. There is currently no hospice waiver. The annual licensing fees are current. The facility maintains liability insurance for the required policy limit minimums with a current policy period of 3/14/23 through 3/14/24. All facility staff were determined to have criminal background clearance. LPA Jensen toured the grounds and observed them to be maintained with all paths free of obstruction. All window screens were observed to be in good repair. There is outdoor furniture and shaded seating areas for clients to engage in outdoor activities. The facility exit/entrances have accessibility ramps. The interior of the facility was observed to be sanitary and adequately furnished. The thermostat was set at 70 degrees for the comfort of the residents. LPA Jensen toured the kitchen and confirmed that a 2 day supply of perishable food and a 7 day supply of non-perishable food is maintained. There is a menu posted and the food being prepared for dinner accurately reflected what was posted on the menu. Cleaning supplies, toxins and knives were observed to be locked and inaccessible to residents in care. LPA Jensen observed 2 kitchen cabinets missing handles. Technical assistance was provided. LPA Jensen toured the resident bedrooms. The facility has 2 private bedrooms and 1 shared bedroom. The bedrooms were observed to contain all required furniture. Each bedroom was personalized to reflect the interests of the individual resident. The facility maintains an adequate supply of bedding and linens.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

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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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: PRATHNA RESIDENTIAL CARE FACILITY FOR THE ELDERLY	FACILITY NUMBER: 507003973
	VISIT DATE: 10/26/2023

NARRATIVE

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LPA Jensen observed all required postings to be displayed in areas easily viewed by residents/staff and visitors. The facility maintains adequate supplies for activities to encourage resident engagement. The first aid kit was observed to be in compliance. LPA Jensen reviewed the emergency disaster plan and found it to be in compliance. The fire extinguisher was purchased on 8/29/23 and is in compliance. The smoke detector and carbon monoxide detector were determined to be in working order. The facility maintains 7 day supply of water in the event of an emergency. There is emergency lighting available.

LPA Jensen toured the facility bathrooms. The master bedroom bathroom was observed to have a bucket underneath the sink with water in it and appears to be leaking. Technical assistance was provided. The temperature in the master bedroom bathroom was measured at 113 degrees which falls within the required range of 105 degrees to 120 degrees. There are night lights available in the hallways and bathrooms. The bathroom shower/tub areas have non-slip mats. There is an adequate supply hygiene products and towels available. The bathrooms have paper towel dispensers for infection control.

LPA Jensen conducted a random medication audit and determined the record keeping to be accurate. A random audit of P&I funds was conducted and the accounting was determined to be accurate. LPA Jensen reviewed 3 of 3 staff files and found all staff files to be complete and in compliance. 4 of 4 resident records were reviewed and found to be complete and in compliance. The facility does not appear to have an updated Infection Control Plan submitted. Technical assistance was provided.

Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview as conducted and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 10/26/2023 12:33 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: PRATHNA RESIDENTIAL CARE FACILITY FOR THE ELDERLY	FACILITY NUMBER: 507003973
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303

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 is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Jensen's observation of a plumbing leak in the master bathroom sink, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/27/2023
	Plan of Correction
1 2 3 4	The Licensee agrees to repair the leak under the bathroom sink and send the repair invoice by email to maja.jensen@dss.ca.gov by the plan of correction 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: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

LIC809 (FAS) - (06/04)

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