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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700433
Report Date: 01/20/2022
Date Signed: 01/20/2022 04:09:38 PM

Document Has Been Signed on 01/20/2022 04:09 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:OFODIRE CARE HOMEFACILITY NUMBER:
342700433
ADMINISTRATOR:OFODIRE, PEARLFACILITY TYPE:
735
ADDRESS:8952 PLAZA PARK DRTELEPHONE:
(916) 230-0690
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 4CENSUS: 3DATE:
01/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:54 PM
MET WITH:Pearl OfodireTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived at the facility unannounced to conduct an annual visit. Facility staff confirmed no residents or staff have displayed any signs or symptoms of COVID-19 in the last 10 days. LPA Valerio was screened for COVID-19 symptoms with temperature taken prior to being allowed pass the front door.

LPA Valerio, Administrator Pearl, and facility staff went over the recent PINs regarding COVID vaccines and booster requirements, and visitation policy. LPA also completed the infection control domain tool during the visit. All staff and residents are currently vaccinated and have received their booster. The facility has a stock of PPE for a minimum of 30 days. The facility has the ability to designate an isolation room and bathroom.

Administrator provided LPA updated copies of LIC 610, LIC 308, and administrator certificates.

LPA and facility staff toured the physical plant to ensure compliance with Title 22 regulations. LPA observed the facility to be clean, organized, and all exits were free from obstructions. Facility staff clean all areas of the facility every couple hours. Residents were observed wearing their masks when outside of their rooms doing activities. LPA observed the temperature inside the facility was measured at 72*F. The hot water was measured at 115*F. Facility has nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. An emergency supply of food and water was also observed. LPA observed the centrally stored medications area and cleaning supplies to be locked and inaccessible to clients. Fire extinguisher is up to date with last check on 06/09/2021.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held, and a copy of the report was left with Administrator Pearl Ofodire.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2022
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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