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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700433
Report Date: 01/22/2025
Date Signed: 01/22/2025 04:57:14 PM

Document Has Been Signed on 01/22/2025 04:57 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:OFODIRE CARE HOMEFACILITY NUMBER:
342700433
ADMINISTRATOR/
DIRECTOR:		OFODIRE, PEARLFACILITY TYPE:
735
ADDRESS:8952 PLAZA PARK DRTELEPHONE:
(916) 230-0690
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 4CENSUS: 4DATE:
01/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:08 PM
MET WITH:Pearl OfodireTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 1/22/2025, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to conduct a required annual visit. Upon arrival, LPA initially met with staff on duty Claire Lailey and stated the purpose of this visit. Administrator Pearl Ofodire was notified and arrived a shortly after.

Administrator holds certification #6040932735 and expires on 10/9/2025. The facility is licensed for a capacity of 4 clients. Present upon arrival were 2 clients in care with 1 staff on duty. The other clients and the other staff on duty arrived later during this visit.

LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed the facility is clean and in good repair. LPA observed required furniture and lighting throughout the facility. LPA observed 2-day perishables and 7-day non-perishables. The hot water temperature was measured at 116*F which was within the required range of 105-120*F. The temperature inside the facility measured at 72*F which was within the required range of 68-85*F.

LPA observed the centrally stored medications area to be locked and inaccessible to clients. LPA observed the fire extinguisher(s) and first aid kits were up to date. LPA observed smoke and carbon monoxide detector(s) in the facility were in good repair. Fire drill record was observed and conducts monthly fire drills. All emergency exits were clear from obstructions.

Continued on 809-C
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: OFODIRE CARE HOME
FACILITY NUMBER: 342700433
VISIT DATE: 01/22/2025
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LPA reviewed 2 client files (C1 and C2), including admission agreement, medical assessments, ambulatory status, and individual program plan. LPA reviewed 2 clients' cash with the administrator and were found to be accurate. Medication review was conducted for C1 and C2. No issues were noted.

LPA reviewed 3 staff files (S1-S3), including health screen, criminal record clearances, and first aid training. A review of staff records indicates that 1 facility staff (S1) has background clearance but not associated to the facility. S1 was associated in 2019. Per interview, administrator never disassociated S1 from this facility. Through interview, S1 went on vacation but came back to work at this facility as a rehire. It was noted that S1 started their employment at this facility on 5/5/2024. Per review of Guardian, S1 was disassociated in 11/01/2020. Administrator was advised to check Guardian to ensure all staff are associated.

The following forms and documents were requested to be submitted within 15 days:
LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, Liability Insurance Certificate, Surety Bond, and LIC 610 Emergency Disaster Plan.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, deficiencies were observed during today's visit. An immediate civil penalty is being assessed for the amount of $500 due to background clearance violation. Failure to correct deficiencies are subject to additional civil penalties.

Exit interview was conducted and a copy of the report and appeal rights was provided upon exit.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
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Document Has Been Signed on 01/22/2025 04:57 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 01/22/2025 at 04:22 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: OFODIRE CARE HOME
FACILITY NUMBER: 342700433

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(3)
80019 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f)

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above. S1 was noted to have fingerprint clearance but not associated to this facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2025
Plan of Correction
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Per discussion, the adminsitrator will submit a transfer request for S1 to the Department by 1/23/2025.
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:Stephen Richardson
LICENSING EVALUATOR NAME:Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2025


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