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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507003973
Report Date: 09/16/2024
Date Signed: 09/16/2024 03:41:01 PM


Document Has Been Signed on 09/16/2024 03:41 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 ELDERLYFACILITY NUMBER:
507003973
ADMINISTRATOR:PRASAD, MUKESHFACILITY TYPE:
740
ADDRESS:3708 CARLISLE COURTTELEPHONE:
(209) 577-2133
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:5CENSUS: 3DATE:
09/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Shirley TudenceTIME COMPLETED:
03:45 PM
NARRATIVE
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On 9/16/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual inspection. LPA Jensen met with care staff provider Shirley Tudence and explained the purpose of today's visit.
LPA Jensen toured the grounds and observed all paths to be free of obstruction. There are shaded areas and patio furniture for client use. There are no bodies of water on the property. The window screens were in good repair. The back yard gate is functional. LPA Jensen observed weeds growing in the gutters. Technical assistance was provided. LPA Jensen toured the interior of the facility. The facility was observed to be sanitary and free of odor. Adequate furnishings and lighting was observed. All toxins, medications and knives were observed to be locked and inaccessible to residents in care. An adequate supply of linens was observed. The facility maintains multiple 1st aid kits which are complete and in compliance. The smoke detector and carbon monoxide detector were observed to be in good working order. The fire extinguisher was last serviced on 8/26/24 and is in compliance. Emergency disaster drills are conducted and logged on a regular basis. The thermostat was set at 75 degrees for the comfort of the residents. The water temperature in the master bath sink was tested and found to be in compliance. There are no leaks in the master bathroom sink. LPA Jensen inspected the kitchen and observed a 2 day supply of perishable food and a 7 day supply of non-perishable food. Fresh fruit and vegetables were available. LPA Jensen reviewed 2 staff files which were observed to be complete with the exception of 1 staff member lacking a criminal background clearance transfer. LPA Jensen reviewed 3 of 3 resident files and observed them to be complete. A random audit on P&I funds was conducted and the accounting was determined to be accurate. Liability insurance and the surety bond were found to be current. LPA Jensen conducted client interviews and clients stated they are satisfied with all aspects of care being received.

A deficiency is being cited pursuant to the California Code of Regulations (CCR), Title 22, Division 6. Civil penalties are also being assessed. An exit interview was conducted and a copy of this report and appeal rights provided.

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2024
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 09/16/2024 03:41 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: 09/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Jensen's review of Guardian, the licensee did not comply with the section cited above in 1 of 2 counts wherein an employee lacking a criminal background clearance transfer was observed on duty which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2024
Plan of Correction
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CoAdministrator Shirley Tudence sent a transfer request to the department in the presence of LPA Jensen. No further plan of correction is required.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2024
LIC809 (FAS) - (06/04)
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