342700936-2-15-2024-27-AS-AVIA-D2GVCH-20240215151911

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700936
Report Date: 02/15/2024
Date Signed: 02/15/2024 03:19:21 PM

Document Has Been Signed on 02/15/2024 03:19 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 HOME II		FACILITY NUMBER:	342700936
ADMINISTRATOR:	OFODIRE, PEARL		FACILITY TYPE:	735
ADDRESS:	9400 FEICKERT DRIVE		TELEPHONE:	(916) 230-0690
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY: 4		CENSUS: 4	DATE:	02/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Pearl Ofodire		TIME COMPLETED:	01:30 PM

NARRATIVE

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On 2/14/2024, at 9:45am, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to conduct the required annual visit. LPA initially met with staff on duty and explained the purpose of the visit. The administrator, Pearl Ofodire, was made aware of the visit and arrived shortly after. Today's visit, there were 1 client in care with 1 staff on duty.

At 10:15am, LPA, accompanied by the administrator, inspected the facility’s physical plant including but not limited to the kitchen, dining room, clients bedrooms, clients bathrooms, laundry room, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. The facility is a one-story structure located in a residential neighborhood. There were no bodies of water on the premises. Outside of the facility was observe to be cleaned and clear of obstructions. Additionally, LPA observed outdoor furniture for residents’ use and covered area for outdoor activities. Entrance, exits and hallways were observed to be clear of obstructions. LPA observed citrus plants that has been planted by clients in care according to the administrator. LPA observed 4 client bedrooms and 2 bathrooms for clients to use. LPA observed beds and bedding supplies were in good condition, adequate lighting was provided, and sufficient storage for the resident's personal belongings. Bed linens, comforters, and bath towels were observed to be stocked during the visit. Bathrooms were cleaned and operational and adequately supplied including with grab bars and non-skid flooring. One of the bathroom is located in bedroom #1.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were locked and not accessible to residents in care. The kitchen and pantry room were inspected, and sufficient 2-day perishable and 7-day non-perishable food was maintained adequately. Room temperature was maintained in the facility at 71 degrees F. Water temperature in one of the bathroom was measured at 112 degrees F. Fire extinguisher was serviced on 11/15/23. Smoke detectors and carbon monoxide were tested and found to be operable during this visit.

Con't to LIC 809-C...

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

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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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 II	FACILITY NUMBER: 342700936
	VISIT DATE: 02/15/2024

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...Con't from LIC 809
Medications were observed to be stored in one of the kitchen cabinet and were observed to be locked and inaccessible to clients in care. Medications were reviewed for accuracy. Facility is using electronic MAR. First aid kit was observed to have incomplete supplies and accessible to staff. During review of the first aid kit, LPA noted missing first aid manual and tweezers. Technical assistance was provided to obtain first aid manual and other necessary first aid supplies. The facility maintains for each resident Centrally Stored Medication, Destruction Record and PRN Log. LPA observed the facility's infection control practices. LPA observed the facility have Personal Protective Equipment (PPE) supplies. All mandated inspection control posters were posted. LPA observed personal rights and complaint information posted. Facility has appropriate internet access available for resident use. LPA observed facility’s activity calendar and sufficient equipment and supplies to meet activity program needs of residents in care. LPA observed client in care doing various activities with the staff on duty during this visit.

During this inspection, LPA conducted an audit of facility files, 4 client files, and 4 staff files for regulatory compliance. All staff noted on LIC 500 have criminal background clearances and associated to this facility. LPA attempted resident interviews and 1 staff interviews. 4 out of 4 client files reviewed contained the required contents including updated admission agreements, medical assessments, and updated appraisal forms as required. 2 out of 4 staff files reviewed have the required contents including health screening, TB results, current first aid/CPR, and initial and ongoing required trainings. 2 of 4 staff was observed to not have current first aid certificate. Facility’s liability insurance is current per regulatory requirements. The facility is their current on annual license fees. Per interview with the administrator, they will enroll those staff needing first aid/CPR training. LPA reviewed facility’s disaster plan to ensure regulatory compliance. Facility conducts quarterly fire drills. LPA requested an updated copy of LIC 500, staff schedule, liability insurance certificate and surety bond certificate.

Per California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 9099-D).

An exit interview was held with Pearl Ofodire, administrator, and a copy of this report and appeal rights were provided to the facility.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. *

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/15/2024 03:19 PM - It Cannot Be Edited

Created By: Arvin Villanueva On 02/15/2024 at 02:06 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 II	FACILITY NUMBER: 342700936
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80075(f)

Health-Related Services

Health Related Services: (f) Staff providing care and supervision shall receive first aid training from qualified agencies including but not limited to the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited above. During staff file review, LPA noted 2 of 4 staff files that were reviewed did not have current first aid certificate, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/22/2024
	Plan of Correction
1 2 3 4	Administrator will review staff files to ensure all staff are First Aid qualified. Administrator to send current first aid certificate to the Department by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 02/15/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

LIC809 (FAS) - (06/04)

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