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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700936
Report Date: 03/27/2024
Date Signed: 03/27/2024 04:10:18 PM

Document Has Been Signed on 03/27/2024 04:10 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 IIFACILITY NUMBER:
342700936
ADMINISTRATOR:OFODIRE, PEARLFACILITY TYPE:
735
ADDRESS:9400 FEICKERT DRIVETELEPHONE:
(916) 230-0690
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 4CENSUS: 4DATE:
03/27/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Pearl OfodireTIME COMPLETED:
04:15 PM
NARRATIVE
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On 3/27/24, at 3pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived to this facility unannounced to conduct a case management visit. LPA initially met with the staff on duty and explained the purpose of the visit. The facility administrator, Pearl Ofodire, was notified and made aware of the visit and arrived shortly after. During this visit, present were four clients in care with two staff on duty.

During today's visit, LPA conducted a facility observation and staff interview. LPA observed clients in care doing their own activities. One client was sitting on the massage chair while the other two was watching TV. During room inspection, one client was in their bed lying down and watching a movie. Per interview with staff on duty, clients just arrived from their day program and just finished their shower. Per staff on duty, they had plan to go for a walk today but it is raining at this time. Staff on duty added they will do alternative activities of their choosing.

This visit is to cite deficiencies as noted during a Title 17 Monitoring Review conducted on 2/22/24 by Alta California Regional Center (ACRC) representatives. The Department was made aware that a medication error was found substantiated during a medication review. ACRC representatives noted the absence of staff signatures on 1 of 4 clients’ Medication Administration Record (MAR) from the morning (7am) of 2/22/24. ACRC representatives also noted that a review of 1 of 4 clients' MAR revealed that one medication was incorrectly inputted in the MAR. Per review of the client's medication stated a different dosage compare to what was inputted in the MAR.

The Department was also made aware that this facility was found substantial inadequacies during personnel record review on 2/22/24. ACRC representatives also conducted personnel records and found that two staff were missing documents that record their required training.

Con't to LIC809-C...

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2024
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: 03/27/2024
NARRATIVE
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Con't from LIC809

Based on documentation review, the facility has complied with the correction plan noted in the Title 17 Monitoring Review report by the stated deadlines of 3/20/24.

Based on LPA’s observations and interview with the facility administrator, the preponderance of evidence standards has been met.

Per California Code of Regulations, Title 22 Division 6, deficiencies are being cited during this visit.

If any deficiencies are not corrected by the noted due dates, civil penalties may be assessed.

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

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

DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/27/2024 04:10 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 03/27/2024 at 03:48 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: 03/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/03/2024
Section Cited
CCR
80075(b)

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80075 Health Related Services: (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
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Licensee has submitted proof of a double check systerm to regional center to ensure all medications are administered correctly and MAR signed appropriately.

POC Cleared prior to today’s visit
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Based on interview and record review, the licensee did not comply with the section cited above as during a Title 17 monitoring review. It was reported in 1 of 4 clients MAR that staff initial were absent from 2/22/24 at 7am med passing and licensee did not ensure the MAR identifies correct medication information in 1 of 4 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
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Licensee submitted a written plan ensuring the MAR identifies correct medication information to the regional center by the due date.

POC cleared prior to today's visit.
Type B
04/03/2024
Section Cited
CCR80064(a)(3)

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80064 Administrator - Qualifications and Duties (a) The administrator shall have the following qualifications: (3) Knowledge of and ability to comply with applicable law and regulation.

This requirement is not met as evidenced by:
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Licensee has submitted an organizational tool to ensure all necessary documents is completed timely to the regional center by the due date.

POC cleared prior to today's visit.

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Based on interview and record review, the licensee did not comply with the section cited above as during a Title 17 monitoring review. It was reported that during a personnel record review, it was discovered that two staff did not have the required traninings available for review during the visit which poses/posed a potential health, safety or personal rights 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: 03/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024


LIC809 (FAS) - (06/04)
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