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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700936
Report Date: 09/26/2022
Date Signed: 09/26/2022 03:24:35 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/08/2022 and conducted by Evaluator Christina Valerio
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220708172342
FACILITY NAME:OFODIRE CARE HOME IIFACILITY NUMBER:
342700936
ADMINISTRATOR:OFODIRE, PEARLFACILITY TYPE:
735
ADDRESS:9400 FEICKERT DRIVETELEPHONE:
(916) 230-0690
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:4CENSUS: 4DATE:
09/26/2022
UNANNOUNCEDTIME BEGAN:
01:47 PM
MET WITH:Pearl OfodireTIME COMPLETED:
03:48 PM
ALLEGATION(S):
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Facility not following resident's ipp plan
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio arrived at the facility unannounced to deliver complaint investigation findings. LPA met with Administrator Pearl Ofodire, and explained the purpose of the visit.

Based on records review, Alta Regional Center made an unannounced visit on 06/15/22. They observed 2 medications that were dispensed on 04/29/22 and 06/06/22 were not listed on the Centrally Stored Medication Record. Records show the administrator was to ensure medications were logged in the Centrally Stored Log by 07/05/222. The facility was also to submit a plan to implement a double-check system. This has been completed LPA observed the Centrally Stored Log for resident 1, which was up to date.

Based on interviews and records review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. CCR (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was conducted with Administrator Pearl Ofodire, and a copy of the report was left.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20220708172342
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOME II
FACILITY NUMBER: 342700936
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/26/2022
Section Cited
CCR
80070(b)(10)
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80070 Client Records (b) Each record must contain information including, but not limited to, the following: (10) Record of current medications, including the name of the prescribing physician, and instructions, if any, regarding control and custody of medications.
This requirement was not met as evidenced by:
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Licensee provided LPA a copy of their double-check system. Licensee to send confirmation of all resident's medications to be logged in the Centrally Stored Medication Record for October 2022.
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Based on observations, record review, and interviews, 1 out of 4 clients medications were not documented on the Centrally Stored Log. This poses a potential health and safety risk to residents 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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2