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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701164
Report Date: 06/23/2023
Date Signed: 06/23/2023 03:07:31 PM

Document Has Been Signed on 06/23/2023 03:07 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:CHIDIKE CARE HOME LLCFACILITY NUMBER:
342701164
ADMINISTRATOR:OFODIRE, PEARLFACILITY TYPE:
735
ADDRESS:8520 SUNRISE WOODS WAYTELEPHONE:
(916) 478-1844
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 4CENSUS: 1DATE:
06/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:12 PM
MET WITH:Ofodire NnaemekaTIME COMPLETED:
03:15 PM
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On 06/023/2023 at 1:10 PM, Licensing Program Analyst (LPA) Pang Lee arrived at this facility unannounced to conduct an annual inspection. LPA Lee arrived and was greeted by facility staff Nnaemeka Ofodire and Direct Support Professional (DSP) Robert Bilbao.

LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. This facility is a single story building licensed to serve four (4) ambulatory clients. LPA Lee observed the facility to be free of odor, clean and in good repair. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present.

LPA Lee observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured at 114.3 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers, smoke and carboxcfgn monoxide detectors are in compliance with fire safety. Fire extinguisher was last serviced on 06/09/203. LPA Lee observed the facility has a has a public telephone in the kitchen and the facility have the required posters posted. The facility has infection control plan and has an emergency disaster plan. Facility thermostat observed at 73 degrees Fahrenheit. LPA Lee checked medication storage and found medication to be locked away and inaccessible to residents. LPA Lee reviewed 1 out of 1 medication administration record (MAR) and it was complete. First aid kit was checked and is complete. LPA Lee requested client and staff files for review. LPA Lee reviewed 3 out of 3 staff files and 3 out of 3 staff files were complete. LPA Lee reviewed 1 out of 1 client file and it was complete. LPA Lee reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility.

Continued LIC 809-C

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2023
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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: CHIDIKE CARE HOME LLC
FACILITY NUMBER: 342701164
VISIT DATE: 06/23/2023
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The following documents was given to LPA Lee during today's visit:
(1) LIC 308 Designation of Administrative Responsibility
(2) LIC 500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC 610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance

Per California Code of Regulations, Title 22, no deficiencies were observed during today’s visit. A copy of this report was provided to the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
LIC809 (FAS) - (06/04)
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