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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345003010
Report Date: 07/26/2023
Date Signed: 07/26/2023 03:03:41 PM


Document Has Been Signed on 07/26/2023 03:03 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 5DATE:
07/26/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Dan Mititi, Administrator TIME COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection to follow up on a third party report received on/around 7/5/23 related to prior resident (R1). LPA met with Dan Mititi, Administrator, and explained purpose of inspection.

LPA discussed the report indicating that resident may not be receiving medications as ordered. Administrator stated that resident moved into the facility over (2) years ago with a diagnosis of Dementia, and that resident had "good days and bad days", didn't sleep a lot at times and would prefer to be in wheelchair or recliner during the awake hours, napping throughout the day. Administrator explained that resident's typical pattern was to be in her wheelchair from 7 am-12:30 pm, change to a recliner 12:30-3:30 pm, and then transfer back to a wheelchair from 3:30 until-bedtime. Administrator stated resident was sent out to the ER on 7/11/23, and was diagnosed with a UTI that day, as confirmed with the family and the hospital. Administrator stated he first observed a significant change on 7/11/23- resident appeared extra drowsy, had less energy with a slower morning and didn't "perk up" as she normally does as the day progresses; he then called 9-1-1 around 2:00 pm.

Administrator confirmed that one family member would visit daily for several hours, and a second family would visit weekly for 3 hours; no concerns were brought to the Administrator's attention. Additionally, resident's nurse practitioner conducted a house-call the week prior and didn't note any changes or concerns. LPA reviewed paperwork and observed the physician's report and care plan to have been updated in June 2023. Administrator also provided a copy of the 30-day move out notice given to him by resident's family on 6/21/23. The note thanks Administrator for providing "very good care" and that resident "has been very happy and comfortable over the last few years". LPA obtained a copy of pertinent documentation. Based on information obtained, the facility contacted family and emergency services timely as required. There are no deficiencies cited. 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: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023
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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