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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002918
Report Date: 10/31/2022
Date Signed: 10/31/2022 10:06:26 AM

Document Has Been Signed on 10/31/2022 10:06 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:ADONAI CARES FOR ELDERLYFACILITY NUMBER:
345002918
ADMINISTRATOR:OLAITAN, SAMUELS OLAWUMIFACILITY TYPE:
740
ADDRESS:5532 HONOR PARKWAYTELEPHONE:
(310) 272-3318
CITY:SACRAMENTOSTATE: CAZIP CODE:
95835
CAPACITY: 6CENSUS: 0DATE:
10/31/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:59 AM
MET WITH:Olaitan, Olawumi, LicenseeTIME COMPLETED:
10:30 AM
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On October 31, 2022 at 9:00am, Licensing Program Analyst (LPA) De Anna Williams-Lyons arrived announced to conducted a Pre-Licensing Inspection of the facility to ensure compliance with Title 22 regulations. LPA Lyons met with Olaitan, Olawumi, Licensee/ Administrator, who assisted LPA in today’s inspection. The Administrator certificate expires 12/13/2022.

Prior to initiating the inspection LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: mask.

The current census is 0. The facilities Administrator’s Certificate, Emergency Disaster Plan, Resident’s Rights and Facility Sketch was available for viewing. The room temperature was 85 degrees F which is within range.

LPA inspected the interior and the exterior of the facility including the common living spaces, the kitchen, resident bedrooms and bathrooms. In the kitchen area, cabinets and drawers were reviewed;. Knives and sharp objects were reviewed to make sure that they were locked and made inaccessible to the residents at all times. LPA observed there to be a sufficient amount of 2-day perishable food in the facility even though there are no residents currently. Hot water temperatures were taken and measured at 110 degrees F, which is within the allowed range of 105-120 degrees. There’s appropriate lighting throughout the facility.

To continue see 809-C...

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2022
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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: ADONAI CARES FOR ELDERLY
FACILITY NUMBER: 345002918
VISIT DATE: 10/31/2022
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The facility is a one story home with 4 bedrooms and 3 bathrooms. Living rooms, dining room, and areas designated for resident use were toured. Furniture and furnishings were observed to be sufficient and in good repair. Resident bedrooms and bathrooms were toured. All rooms had the required items of furniture. Window screens were on and in good repair. Bathrooms were clean, sanitary and odorless and consisted of grab bars and non-skid mats. Hot water temperature is 110 degrees F. The sink, toilet, bathtub and shower operate properly. The facility has a sufficient supply of linens, towels, bedding, etc. for residents in care. Washer and dryer was present and operating properly. Toxic substances, laundry and cleaning supplies are inaccessible..

First aid kit was present and included the required scissors, tweezers, thermometer and guide. Fire alarms, smoke alarms, and carbon monoxide detectors operate properly. Fire extinguisher is maintained and ready for emergency use and in compliance at this time. There is a centralize storage area for the resident's medication that has a lock LPA inspected the exterior grounds of this facility. There are no bodies of water on the premises. The perimeter fence, side gates, and latches were in good repair. LPA observed shaded areas in the backyard and garage to be very clean and is organized. Passageways are free of obstruction and potential hazards.

LPA is recommending Licensure however, it is pending approval from Central Application Unit.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies were observed today.


An exit interview was conducted and a copy of this report was given to Olawumi.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
LIC809 (FAS) - (06/04)
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