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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004197
Report Date: 05/21/2021
Date Signed: 05/21/2021 03:02:06 PM

Document Has Been Signed on 05/21/2021 03:02 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:OHANA HOSPITALITYFACILITY NUMBER:
347004197
ADMINISTRATOR:AGNES SUMAGITFACILITY TYPE:
740
ADDRESS:5117 HEATHER RANCH WAYTELEPHONE:
(916) 534-7707
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95742
CAPACITY: 6CENSUS: 5DATE:
05/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Administrator, Agnes SumagitTIME COMPLETED:
03:30 PM
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On 5/21/21 at 2:00pm Licensing Program Analysts (LPAs) Kevin Gould and Anthony Tuck conducted an unannounced required 1 year inspection. LPAs met with Administrator Agnes Sumagit and together conducted a tour of the facility. The facility is a six bed single story residence in a residential home. LPAs observed five (5) bedrooms three and a half (3 1/2) bathrooms, living room, family room, large kitchen and dining room.

LPAs toured common rooms such as the living room, dining room, and all other areas designated for resident use were toured and observed to be in compliance at this time. Furniture and furnishings were observed to be sufficient to meet the needs of the residents at this time. Kitchen area was toured. Food supply for required 2-day perishable and 7-day non perishable food quantities were observed to be sufficient and able to meet the needs of the residents at this time. Fire extinguishers were observed to have been annually assessed on 04/05/2021 by the local fire authority and found to be in compliance at this time. Medication cabinet was observed to be locked and made inaccessible to the residents at this time. Laundry area was toured. Cleaners and detergents were observed to be locked and made inaccessible to the residents at this time.
A tour of the resident bedrooms was conducted. It was observed that bedroom furniture and furnishings were in good repair and sufficient to meet the needs of the residents at this time. A tour of the resident restrooms was conducted.

LPAs inspected the attached garage and observed additional food storage fridge and freezer. LPAs inspected the back yard and observed no hazards to residents in care. There is a small fountain in the front porch about the size of a sink that does not pose a danger to residents and does not meet definition of a body of water.

There were no deficiencies observed or cited during today's annual inspection per Title 22 regulations.

Exit Interview was conducted with Facility Administrator and a copy of the report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2021
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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