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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005433
Report Date: 08/15/2022
Date Signed: 08/29/2022 03:37:33 PM

Document Has Been Signed on 08/29/2022 03:37 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:PRASAD'S CARE HOMEFACILITY NUMBER:
347005433
ADMINISTRATOR:SANJEETA PRASADFACILITY TYPE:
740
ADDRESS:4250 ARCHEAN WAYTELEPHONE:
(916) 431-7132
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 6CENSUS: 5DATE:
08/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Gyaneshwari KashyapTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Staff and explained the purpose of the visit. Administrator was out of town and unavailable for this inspection.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 115 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees.

Fire extinguishers is in need of service, however the smoke detectors and carbon monoxide detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 5 resident and 2 staff files, including criminal record clearances. During the review of the resident file; LPA observed outdated Physician's report for R1 and R3 also observed outdated service plans for R1, R2 and R3. First aid kit was checked and is complete. LPA was unable to determine when the facility last conducted a fire drill.

Per the Title 22, Division 6 of California Code of Regulations. Deficiencies were observed during today's inspection. Exit interview conducted.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2022
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 08/29/2022 03:37 PM - It Cannot Be Edited


Created By: Albert Johnson On 08/15/2022 at 10:35 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PRASAD'S CARE HOME
FACILITY NUMBER: 347005433

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/16/2022
Section Cited
CCR
87203

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87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
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Licensee will submit a proof of purchase or fire inspection and complete a fire /disaster drill to LPA by POC due date of 8/16/2022
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This requirement is not met as evidenced by: LPA and S1 observed a fire extinguisher without purchase receipt or inspection record and no record of a fire drill which poses an immediate risk to residents in care.
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Type A
08/16/2022
Section Cited
CCR87465(h)(2)

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87465(h)(2) Incidental Medical and Dental Care Services. Centrally stored medications shall be kept in a safe locked place that is not accessible to persons other than employees responsible for the supervision of the medication.
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Licensee/Administrator shall conduct in-service training with staff to ensure that all items that could pose a danger to residents are kept locked and inaccessible at all times. Proof of correction to be sent to CCLD by POC date indicated.
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Based on observation LPA and staff observed centrally stored medications are not kept locked and are accessible to residents. Medications were located in the unlocked refrigerator
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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:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/29/2022 03:37 PM - It Cannot Be Edited


Created By: Albert Johnson On 08/15/2022 at 11:00 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PRASAD'S CARE HOME
FACILITY NUMBER: 347005433

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/26/2022
Section Cited
CCR
87705(c)(5)

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Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
This requirement is not met as evidenced by:
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Administrator will arrange to obtain an updated 602 for identified residents in 10 days . Licensee will obtain the updated 602 in 10 days and will provide proof via email to LPA
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Based on record review and interview, the licensee failed to have current Physician's reports for R1 and R3
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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:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2022


LIC809 (FAS) - (06/04)
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