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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345003010
Report Date: 06/09/2023
Date Signed: 06/09/2023 03:20:05 PM


Document Has Been Signed on 06/09/2023 03:20 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 NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:OHANA CARE HOMEFACILITY NUMBER:
345003010
ADMINISTRATOR:MITITI, DANFACILITY TYPE:
740
ADDRESS:8254 MOSS OAK AVETELEPHONE:
(916) 879-0879
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 6DATE:
06/09/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Dan Mititi, Administrator TIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a pre-licensing inspection for a change in ownership. LPA met Dan Mititi, Administrator,and explained purpose of inspection. Also present was caregiver, Alexa Mititi. LPA observed (3) residents in the common area and (3) residents in their rooms. The facility is currently licensed for (6) non-ambulatory residents and has a hospice waiver for (3) residents. Currently, there is (1) resident on hospice.

LPA and Administrator toured the interior and exterior of the facility including the common areas, (4) private resident bedrooms, (1) shared resident bedroom (2) resident bathrooms with walk-in showers, kitchen, office, staff room and outside laundry area. LPA observed the facility to be clean, in good repair and to have sufficient furniture and lighting and the bathrooms to have the necessary grab bars, non-skid flooring, paper towels and hand-washing posters. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food in the kitchen and sharps to be locked in a kitchen cabinet with a toddler lock. During the inspection, Administrator transferred the knives to a locked box temporarily and agreed to install a magnetic/key lock on a kitchen drawer. LPA observed locked medications in the office, locked toxins in the laundry area and an empty pool to be gated and locked. LPA observed a patio table, chairs and cover with a ceiling fan and (1) unlocked exit gate. LPA observed the inside temperature to be 74*F. Fire extinguisher was last serviced on 11/10/2022 and all doors have alarms. LPA observed a complete First Aid kit and PPE supplies. (1) smoke/monoxide alarm was tested and observed to be functioning. Administrator to change batteries in all detectors to ensure the green light is visible. Water temperature measured at 112*F in one resident bathroom. LPA observed sufficient linens/towels/paper supplies. LPA observed various required postings, including Theft & Loss Policy, blank admission agreement and visitation policy. (2) resident binders and (2) staff files were reviewed and found to contain current documentation, including for training. Component III was reviewed during today’s inspection. Pre-Licensing is complete with no deficiencies- Administrator to send photo documentation that a lock has been installed for knives.
Exit interview. Copy of report provided to Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2023
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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