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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700801
Report Date: 09/25/2024
Date Signed: 09/25/2024 03:29:27 PM


Document Has Been Signed on 09/25/2024 03:29 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:MINNESOTA HOME CAREFACILITY NUMBER:
342700801
ADMINISTRATOR:OKYERE, VERA A.FACILITY TYPE:
740
ADDRESS:7448 MINNESOTA DR.TELEPHONE:
(916) 729-9461
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 4DATE:
09/25/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Vera Okyere, Administrator TIME COMPLETED:
03:30 PM
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Licensing Program Analysts (LPA) Sabrina Calzada and Todd Tryon arrived unannounced to conduct a case management inspection. LPA's met with Vera Okyere, Administrator, and explained purpose of inspection. There are currently (4) residents who live at the home and (1) resident receives hospice care.

Also present was Lydia Awuku, caregiver. LPA's observed (1) resident watching television in the common area and another resident return to the facility. There were (2) residents resting in their rooms.

LPA's discussed resident (R1) who moved to the facility on/around 8/26/24 and was sent to the emergency room on 9/11/24. (R1) remained in the hospital until 9/21/24, where they passed.

LPA's obtained copies of paperwork from (R1's) file. LPA's discussed if an incident report was submitted to the Department within (7) days of (R1) being sent to the emergency room and admitted. LPA's were provided with a copy of the completed incident report and fax receipt showing it was faxed to the Department on 9/14/24 (4:03 am).

LPA's toured the facility and observed it to be clean, safe and in good repair. LPA's observed (R1's) wallet and contents. Photos were taken.

LPA's discussed providing the Department with additional documentation relating to (R1's) property by 9/26/24.

Administrator agreed to submit a completed death report (LIC624A) to the Department by 9/28/24.

There are no deficiencies issued in this report.

Exit interview. Copy of report provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024
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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