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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701253
Report Date: 03/10/2025
Date Signed: 03/10/2025 04:35:46 PM

Document Has Been Signed on 03/10/2025 04:35 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:
03/10/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Uzodinma OfodireTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst(s) Victoria Brown and Sommer Hayes arrived unannounced to conduct a Case Management visit on 3/10/25 at 3p. LPAs met with 2 caregivers who contacted the Administrator regarding the purpose of todays visit.

Community Care Licensing (CCL) received an Incident report indicating that resident # 1 (R1) was found to be involved in an unsafe wander situation. R1 was not located by staff during a room check.

An Incident report was submitted to CCL indicating at approximately 6:30p on 3/5/25 R1 was discovered to not be in the room. Law enforcement was contacted who located R1 at approximately 6:50p.

LPAs observed that the alarm on the slide door to the backyard was not operable during this visit.

The Investigation revealed that R1 could not leave the facility unassisted as stated in the Physician Report (LIC602) dated 1/6/25.

Based on LIC602 and the LIC624 that was submitted the facility will be cited during this visit as R1 left facility without supervision.

Per California Code of Regulations (CCRs) - Title 22, Div.6, Ch. 6, deficiencies are being cited on the attached 809D during this visit. If any deficiencies are not corrected by the noted due dates; civil penalties may be assessed. A copy of their rights was provided (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, a copy of this report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2025
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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Document Has Been Signed on 03/10/2025 04:35 PM - It Cannot Be Edited


Created By: Victoria Brown On 03/10/2025 at 03:57 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: 03/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/19/2025
Section Cited
CCR
80078(a)

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Responsibility for Providing Care and Supervision
The licensee shall provide care and supervision as necessary to meet the client's needs.
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Administrator shall submit by fax a statement that the alarms will be purchased from amazon and installed on the house exits.
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This requirement was not met as evidenced by: Based on observation and admittance of Administrator that R1 was not observed in the facility during a room check.
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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:Victoria Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2025


LIC809 (FAS) - (06/04)
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