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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701085
Report Date: 09/26/2024
Date Signed: 09/26/2024 02:45:20 PM

Document Has Been Signed on 09/26/2024 02:45 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:IRENE'S CARE HOME INC. #2FACILITY NUMBER:
342701085
ADMINISTRATOR/
DIRECTOR:		OGBEIWE, IRENEFACILITY TYPE:
735
ADDRESS:3940 DEERBROOK DRIVETELEPHONE:
(916) 813-2747
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 4CENSUS: 4DATE:
09/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:55 AM
MET WITH:Irene OgbeiweTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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 On 09/24/2024 at 11:55 AM PM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA met with administrator Irene Ogbeiwe. LPA explained the purpose of the visit. The current census is 4 with 1 facility staff.

This facility is a single story building licensed to serve 3 ambulatory and 1 non-ambulatory clients. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, client’s bedrooms, client’s bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility to be free of odor, clean and in good repair. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting.

LPA toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. LPA observed knifes kept and made inaccessible to clients in care. Hot water temperature was measured at 119.1 degrees Fahrenheit in client bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in the dining room and was last serviced on 05/29/2024. The last fire drill was conducted on 09/20/2024. LPA observed the facility has a has a public telephone in the common area. Facility thermostat observed at 75 degrees Fahrenheit. LPA observed toxins kept locked and inaccessible to clients. LPA checked medication storage and found medication to be locked away and inaccessible to clients. LPA reviewed and compared 4 out of 4 medication administration record (MAR) and it was complete. The first aid kit was checked and contained all the required components. LPA requested client and staff files for review. LPA reviewed 4 out of 4 clients files and 2 out 2 staff files, and they were complete.

As a result of this annual visit, the facility is in compliance with Title 22 Regulation. An exit interview was conducted, and a copy of these LIC 809 reports were provided to the facility.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024
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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