347004197-5-4-2022-27-AS-KGOD-CE4Q5Q-20220504115220

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347004197
Report Date: 05/04/2022
Date Signed: 05/04/2022 11:52:30 AM

Document Has Been Signed on 05/04/2022 11:52 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	OHANA HOSPITALITY		FACILITY NUMBER:	347004197
ADMINISTRATOR:	AGNES SUMAGIT		FACILITY TYPE:	740
ADDRESS:	5117 HEATHER RANCH WAY		TELEPHONE:	(916) 534-7707
CITY:	RANCHO CORDOVA	STATE: CA	ZIP CODE:	95742
CAPACITY:	6	CENSUS: 5	DATE:	05/04/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Agnes Sumagit, Licensee		TIME COMPLETED:	12:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 5/4/22 at 9:10am Licensing Program Analyst (LPA) Kevin Gould arrived at Ohana Hospitality for the purpose of conducting a required 1 year annual inspection. LPA met with Licensee Agnes Sumagit and together conducted a tour of the home. LPA and Licensee evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA measured the hot water temperature, temperature measured at 115 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents. LPA observed the Administrator's and backup administrator's administrator certificates had both expired. Administrator's certificate expired 3/13/22 and has yet to submit application for renewal. Backup Administrator's certificate expired 7/25/2020 and also has not submitted application for renewal. LPA reviewed staff files and did not observe annual training being conducted and documented for current staff members. LPA also observed a staff member present at the facility who was not associated to the facility. LPA asked Licensee if the staff had been fingerprinted or background cleared and LPA was informed he had not been and was an emergency staff as the regularly scheduled staff member had called out. LPA asked that the uncleared staff member be sent home and the Licensee immediately complied and sent the staff member home. Another cleared staff member arrived shortly after the staff member was sent home. Report continued on LIC 9099-C.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: OHANA HOSPITALITY	FACILITY NUMBER: 347004197
	VISIT DATE: 05/04/2022

NARRATIVE

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LPA observed the medication administration administration records (MARs) for residents to be complete for the month of April but were missing the morning medications for todays date. LPA advised the importance of completing the MARs immediately after the medication is given to prevent any errors in medication administration.
LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 500 personnel report, and Client Roster.

Per California Code of Regulations, Title 22 the following deficiencies were cited during today's inspection. An exit interview was conducted, and a copy of this report and appeal rights were left at the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/04/2022 11:52 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: OHANA HOSPITALITY	FACILITY NUMBER: 347004197
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87412(a)(13)(B)1

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e). 1. For Certified Administrators, a copy their current and valid Administrative Certification meets this requirement. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observations and review of facility documents LPA observed the Administrator's and backup administrator's administrator certificates are both expired. Administrator's certificate expired 3/13/22 and has yet to submit application for renewal. Backup Administrator's certificate expired 7/25/2020 and also has not submitted application for renewal which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/05/2022
	Plan of Correction
1 2 3 4	Licensee will submit all completed hours for Administrator recertification on 5/5/22 and reach out to other facility contacts and former employees with current Administrator certificate and will attempt to appoint a new new administrator and submit all required documents by the POC due date.

Type A

Section Cited

CCR

87355(e)(1)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observations and statements obtained from the Licensee, the licensee did not comply with the section cited above as LPA observed individual Leo Sumagit working at the facility with residents without a criminal record clearance or being associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/05/2022
	Plan of Correction
1 2 3 4	Licensee will have the emergency staff member fingerprint cleared and associated to the facility and will submit a written plan of correction including the specific steps the Licensee will take to ensure all staff are fingerprint cleared and associated to the facility prior to working with residents.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/04/2022 11:52 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: OHANA HOSPITALITY	FACILITY NUMBER: 347004197
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs review of staff files, LPA observed that two of three staff files reviewed did not include 20 hours of annual training for facility staff which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/05/2022
	Plan of Correction
1 2 3 4	Facility will submit a written plan of correction detailing the timeline for ensuring all staff are current with their annual trainings. The written plan will include who requires training, the type of training that is identified to meet the specific needs of residents and will ensure the training will meet dementia and hospice requirements.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

LIC809 (FAS) - (06/04)

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