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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880975
Report Date: 03/16/2021
Date Signed: 03/19/2021 12:29:31 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:OHANA HOMECARE, INC.FACILITY NUMBER:
331880975
ADMINISTRATOR:ELIZABETH RAZONFACILITY TYPE:
740
ADDRESS:69814 FATIMA WAYTELEPHONE:
(760) 620-5390
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY:6CENSUS: 0DATE:
03/16/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Elizabeth Razon, AdministratorTIME COMPLETED:
11:00 AM
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Licensing Program Analysts (LPAs) Tricia Danielson and Yolanda Delgado conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 10:00 AM, LPAs met with Licensee/Administrator Elizabeth Razon via FaceTime. An initial application to operate a Residential Care for the Elderly (RCFE) was submitted to the Central Applications Bureau (CAB) on 09/16/20 for a total capacity of six (6) non-ambulatory clients. Fire Clearance was granted for six (6) non-ambulatory clients, one (1) of which may be bedridden, on 09/22/20. LPAs Danielson and Delgado observed the following:
Structure:
Facility was a one story house with four (4) resident bedrooms, one (1) caregiver bedroom, three (3) bathrooms, living room, dining area and kitchen. There was an attached two car garage in the front of the house.
Heating/Cooling System:
Central heating and air conditioning system installed with a central panel located in the hallway to control entire house.
Bedrooms:
Each client bedroom will accommodate any ambulatory resident. All resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm detector. Per AD, bedroom #1 has been designated and approved to accommodate a bedridden resident.
Bathrooms:
All bathrooms have a working toilet, wash basin, with an adequate supply of paper towels, toilet paper, and soap. Only two (2) of the facility's bathrooms have showers. LPAs observed the showers to have the required grab bars and non-skid mat. At 10:20 AM, LPAs observed AD testing bathroom water temperature. LPAs verified water temperature was measured at 105.6 degrees Fahrenheit.
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Cleaning supplies and knives/sharp instruments were secured in a locked cabinet in the kitchen and garage. There was adequate
(CONTINUED ON LIC 812C)
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2021
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: OHANA HOMECARE, INC.
FACILITY NUMBER: 331880975
VISIT DATE: 03/16/2021
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(CONTINUED FROM LIC 812) room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals for all residents. Laundry area with washer and dryer were located in the garage.
Living/Family room:
There was a living/family room with safe and adequate seating for all residents as well as working TV.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the main hallway of the residence.
Yards/Outside:
There was a patio with adequate covered seating for all residents. Fencing secured the entire backyard. There was a swinging gate on the right side of the property which was observed to not be self latching. All outdoor pathways were free of obstructions. There were no bodies of water observed anywhere on the property.
Garage:
There was a washer and dryer located in the garage. Laundry detergents and cleaning solutions were secured and inaccessible to residents. 72 hour emergency supplies were also storage in the garage. Garage was free of obstructions.
Emergency Phone Numbers, and Exit Plan:
Let-Us-No poster, Ombudsman poster, and emergency phone numbers were posted on the wall in the hallway. Emergency exit route/maps were posted throughout the facility.
General items:
Fire extinguisher was charged and mounted in the dining area. Six (6) smoke alarms and one (1) carbon monoxide detector were tested and were in working order. Flashlights for use in the event of an emergency were observed on each resident's night stand and were found to be operational. Resident records will be stored in a locked closet. First Aid kit with required components, and locked area for medication storage was observed. LPAs observed a facility phone and it was verified to be operational as evidenced by LPA dialing the number to trigger a ring.
Pre-Licensing is incomplete with the following deficiencies to be resolved by 3/22/2021:
The gate leading from the front yard to the backyard must be spring loaded to be self latching.
Applicant will notify LPA of completion of the above items and a follow up pre-licensure LIC809 will be generated upon resolution of deficiencies. Component III was waived and has been previously completed upon licensure of Licensee's two other facilities. The license will be granted based on final review by and approval from the Central Applications Bureau.
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2021
LIC809 (FAS) - (06/04)
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