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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507003973
Report Date: 09/23/2025
Date Signed: 09/23/2025 11:46:43 AM

Document Has Been Signed on 09/23/2025 11:46 AM - 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/
DIRECTOR:		PRASAD, MUKESHFACILITY TYPE:
740
ADDRESS:3708 CARLISLE COURTTELEPHONE:
(209) 577-2133
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 5CENSUS: 1DATE:
09/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:48 AM
MET WITH:Shirley Tudence, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 9/23/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived at the facility unannounced to conduct a required 1-year annual inspection. LPA Lindstrom met with care staff provider Helen Retirado and explained the purpose of the visit. The Administrator joined the site visit at 11:00 AM. The Administrator’s certificate # is 7023863740, expiration 11/9/2026.

The facility is a four-bedroom, two-bathroom house in a residential neighborhood. There were two on-duty staff and one resident at the facility at the time of the visit. Both staff have criminal background clearances. The current census is four.

LPA Lindstrom toured the interior of the facility. The interior was clean, orderly, and odor-free. The required documents were hanging on the wall in the entry way. The living room and dining room contained enough furniture for all residents. The four bedrooms were occupied by single residents. Each bedroom was clean and contained the required furniture. The two bathrooms were clean, odor-free and included grab bars and non-slip flooring. The hot water in the hallway bathroom was 110 degrees Fahrenheit, within the required range. A hallway closet contained extra towels and bedding, as well as cleaning supplies and extra toiletries in a locked cabinet. The kitchen was clean and sanitary. LPA Lindstrom observed a two-day supply of perishable food and seven-day supply of non-perishable food in the kitchen cabinets and refrigerator, as well as a refrigerator in the garage. All sharps, cleaners, and toxins were in locked drawers and cabinets in the kitchen. The LPA observed multiple first aid kits that contained the required items. The fire extinguisher was located in the kitchen and was last serviced on 8/15/2025 by Jorgensen Co. The smoke and carbon monoxide detectors were in working order. The backyard was manicured, had an intact perimeter fence, and included a shaded area with seating. The walkways on the grounds were free of obstruction.

(continued on LIC809-C)

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 09/23/2025
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LPA Lindstrom inspected facility records, including two staff records and four resident records. The staff and resident records were complete. LPA Lindstrom did an audit of two residena's cash resources managed by the facility and verified its accuracy. LPA Lindstrom observed resident medication stored in a locked cabinet. The paper-based medication administration records and centrally stored medication and destruction records were complete and up to date. The facility conducts disaster drills monthly and maintains a log of each drill. The Administrator reviews and updates the infection control plan and emergency disaster drill on a yearly basis.

As a result of this inspection, no deficiencies were cited. The facility was in compliance with the California Code of Regulations (CCR), Title 22, Division 6



An exit interview was conducted with the Administrator, to whom a copy of this LIC 809 report was provided. Their signature below confirms receipt of this document.
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2025
LIC809 (FAS) - (06/04)
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