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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701253
Report Date: 05/30/2025
Date Signed: 05/30/2025 03:43:36 PM

Document Has Been Signed on 05/30/2025 03:43 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:IKENNA CARE HOMEFACILITY NUMBER:
342701253
ADMINISTRATOR/
DIRECTOR:		OFODIRE, UZODINMAFACILITY TYPE:
735
ADDRESS:9866 FALCON MEADOW DR.TELEPHONE:
(713) 516-4867
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 4CENSUS: 4DATE:
05/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:38 AM
MET WITH:UZODINMA OFODIRETIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 05/30/2025 an unannounced annual inspection was made to this facility by Licensing Program Analyst (LPA) Sommer Hayes and Licensing Program Manager (LPM) Stephen Richardson. The LPA/LPM identified themselves and the purpose of the visit and asked to speak to the Designated Facility Administrator. LPA was met by Uzodinma Ofodire the Designated Facility Administrator and a brief interview followed. The facility tour was conducted by the Administrator, Uzodinma Ofodire.

The kitchen was accessible to residents and clean and sanitary. The LPA observed 7 days of non-perishable and 2 days of perishable food supplies. Freezer is -1 degrees F. Refrigerator is 37 degrees F. There is enough clean plates and cutlery to meet capacity. Opened packages in the refrigerator were dated appropriately. All pantry items were dated as well.

The garage was accessible to residents with supervision, clean and sanitary. The garage contained cleaning tools including mop buckets, fans and brooms. Administrator stated residents can use the laundry room with or without supervision depending on the needs of residents. LPA observed laundry soap and chemicals were inaccessible to residents and required staff assistance to unlock, if applicable.

LPA/LPM observed the backyard of the facility to be clean and free of obstruction. There was a shaded area for residents to enjoy. There were no bodies of water. The gate was equipped with a self-latching lock.

LIC 809-C to follow


NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Sommer Hayes
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: IKENNA CARE HOME
FACILITY NUMBER: 342701253
VISIT DATE: 05/30/2025
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LPA/LPM observed a resident eating snacks and learning alphabets in the living room. The facility living room was clean and free of obstruction. The temperature reading was 73 degrees Fahrenheit per Title 22 regulations. The seating is efficient seating for the number of residents in this facility. The fireplace was inaccessible to residents. The fire extinguisher was observed in the living room and was last serviced on 02/01/2025.

In Bathroom #1 LPA/LPM observed the first hallway bathroom to be clean and in good repair. There was a walk-in shower and linen closets with extra blankets and linens for beds. Water temperature was 123 degrees Fahrenheit, higher than the range of 105 to 120 degrees per Title 22 regulations. In bathroom #2 LPA/LPM observed a hallway bathroom to be clean and in good repair. The temperature was 128 degrees Fahrenheit, higher than the range of 105 to 120 degrees per Title 22 regulations. LPA/LPM observed smoke & carbon monoxide detectors were present and in compliance with Title 22 regulations.

LPA inspected all resident bedrooms. All resident rooms had the required furniture, furnishings and lighting to be in compliance at this time. Bedrooms # 1, # 2, #3 was single occupancy. There were clean linens, mattress covers and bedspreads.

LPA/LPM observed the centrally stored medication cabinet to be locked and inaccessible to residents. All residents’ medications are individually stored in blue boxes and no medications were expired. In addition, there was a working landline telephone that was fully operational.

Staff/Resident Record Review LPM conducted a file review of 4 of 4 client files and 5 of 5 staff files. All required documentation was found to be present and current. LPA further observed the facility to be conducting disaster drills monthly with the last drill being conducted in April 2025 at 2:30am with 4 residents. The Administrator stated that they assist clients with cash resources for three residents.


Per California Code of Regulations (CCR) - Title 22, two (2) deficiencies were observed today. An exit interview was held, and a copy of the report was provided.
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Sommer Hayes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/30/2025 03:43 PM - It Cannot Be Edited


Created By: Sommer Hayes On 05/30/2025 at 02:34 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: IKENNA CARE HOME
FACILITY NUMBER: 342701253

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80086(a)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on an interview with the Administrator, observation from LPA/LPM of the approved Facility Sketch and Plan of Operation. The Licensee modified the garage from the original sketch to create three staff rooms without notifying the Regional Office. This posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2025
Plan of Correction
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Licensee will submit an updated Facility Sketch to be reviewed and approved by LPA Sommer Hayes
Type B
Section Cited
CCR
80087(a)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation during the facility walk through LPA observed that three fence boards were in need of being replaced. This posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2025
Plan of Correction
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Licensee will replace the fence boards in the back yard of the facility. The licensee will send proof to LPA Sommer Hayes via email at sommer.hayes@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Sommer Hayes
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2025


LIC809 (FAS) - (06/04)
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