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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345003010
Report Date: 04/08/2024
Date Signed: 04/19/2024 10:32:29 AM


Document Has Been Signed on 04/19/2024 10:32 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
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: 4DATE:
04/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Dan Mititi, Administrator TIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual and met with Dan Mititi, Administrator. Caregiver, Harlene Henry was also present. LPA observed all (4) residents to be in their rooms at the start of the inspection. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (3). 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, (1) staff room, kitchen, laundry area, and office area. LPA observed the facility to be clean, in good repair and odor-free. LPA observed the bathrooms to have the necessary grab bars, non-skid flooring, paper towels and hand-washing posters. There is sufficient 2+ day perishable and 7+ day non-perishable supply of food. Sharps are locked in the kitchen, medications are locked in the office area, and toxins are locked in the outside laundry area. The inside temperature measured 71*F, and the hot water temperature measured 106*F in the kitchen. Facility conducts quarterly fire drills. Smoke/monoxide alarms are working. Fire extinguisher was last serviced 10/23/2023. There are sufficient towels/linens/PPE/paper and incontinent products. All required postings are in the common area. LPA observed (1) unlocked gate from the outside patio and also covered patio seating. There is an empty pool that is locked and gated.First aid kit is complete. LPA reviewed/approved the Infection Control Plan and found it complete. Emergency Disaster Plan was also reviewed.

LPA reviewed (3) resident files and found them to be complete with current physician's reports and care plans. Medications were reviewed for (2) residents and orders matched medications being administered. Medication documentation is current and PRN dosages are being recorded. LPA reviewed (3) of (3) staff files, which were organized and complete. Current training documentation, including First Aid/CPR, was on file. All staff are cleared and associated to the facility. Discussed Guardian updates to manage roster. RCFE Administrator certificate #6006514740 is pending renewal. LPA obtained an updated copy of the LIC308, LIC500, and current of liability insurance.
There are no deficiencies issued during today's inspection. Exit interview. Copy of report provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2024
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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