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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700433
Report Date: 12/04/2024
Date Signed: 12/04/2024 03:58:07 PM

Document Has Been Signed on 12/04/2024 03:58 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:
12/04/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Staff on duty (S1)TIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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On 12/4/2024 at 3pm Licensing Program Analyst (LPA) Arvin Villanueva conducted an unannounced Case Management visit to address deficiencies recorded during a regional center inspection of the facility on 3/24/24 and the Facility Action Report (FAR) generated as a result of the inspection. LPA met with staff on duty and stated the purpose of the visit. The administrator, Pearl Ofodire, was notified of the visit over the phone and together reviewed the FAR changes made to remain in compliance with Title 17 and Title 22. Present during today's visit were 3 residents in care with 2 staff on duty.

Per FAR, on 3/21/2024, Alta California Regional Center (ACRC) staff conducted the annual Title 17 monitoring review at this facility. During the review, the following issue(s) were identified: during personnel file review, the DSP Year 2 for a staff member (S2) was due on July 21, 2023, which has not been completed.

During this visit, the LPA conducted a discussion over the phone with the administrator regarding the corrective actions taken to address the identified deficiencies. According to the administrator, S2 has completed the required DSP Year 2 training and has submitted the corrections to ACRC. The administrator is currently unable to come to the facility in person but will submit the staff member’s DSP Year 2 certificate and FAR clearance letter to the Department by 12/5/2024. The administrator gave permission to S1 to sign this report.

Per California Code of Regulations, Title 22 the following deficiency is cited.

Exit interview conducted and a copy of this report and appeal rights were left at the facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
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 12/04/2024 03:58 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 12/04/2024 at 03:34 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: 12/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/11/2024
Section Cited
CCR
80064(a)(3)

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Administrator - Qualifications and Duties: The administrator shall have the following qualifications: Knowledge of and ability to comply with applicable law and regulation.

This requirement is not met as evidenced by:
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 Per discussion with the administrator, the required corrective action plan set by ACRC has been completed.
Administrator agreed to submit the proof of DSP Year 2 certicate and FAR clearance letter to the Department by POC due date.
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The licensee did not comply with the regulation noted above. During Title 17 monitioring review, 1 staff did not complete the required DSP Year 2. This poses a potential health, safety and personal risk to persons in care.
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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: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2024


LIC809 (FAS) - (06/04)
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