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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004197
Report Date: 03/28/2024
Date Signed: 08/15/2024 02:40:08 PM


Document Has Been Signed on 08/15/2024 02:40 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 6DATE:
03/28/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Agnes SumagitTIME COMPLETED:
11:08 AM
NARRATIVE
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On 03/28/24, a scheduled Office Meeting was conducted via Microsoft Teams for the purpose of discussing the status of Ohana Hospitality license.  Present at the meeting were Licensing Program Manager (LPM) Stephen Richardson, Licensing Program Analyst (LPA) Kimberly Viarella, and Licensee of record, Agnes Sumagit.

LPM Richardson led the meeting and asked Agnes Sumagit questions regarding the process and timeline for the transfer of ownership of the business to employee, Renilyn Campos. The LPM also explained the process that Community Care Licensing required for a change of ownership. The LPM went on to explain one of the conditions for forfeiture of a license.

According to the California Code of Regulations (CCR) 87112(a) Conditions for forfeiture of a residential care facility for the elderly license shall be as specified in Health and Safety Code section 1569.19, which provides in part:  "A license shall be forfeited by operation of law prior to its expiration date when one of the following occurs: (a) The licensee sells or otherwise transfers the facility or facility property...."

When Agnes Sumagit sold Renilyn Campus Ohana Hospitality on May 1, 2023, Agnes forfeited her license and Ohana Hospitality became an unlicensed facility.  A Notice of Violation of Law (NOVL) and Forfeiture of License will be delivered. A citation for this deficiency may be found on the LIC 809 D page.

Agnes Sumagit stated that she will complete the following: 

- Forward the email notification letters sent to all the residents and/or their responsible parties for the resident in care at the time of the transfer so the Department may ensure they retained all of the required elements. These letters should contain the reason for the sale, as well as to let the residents know that they had the option to relocate.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: OHANA HOSPITALITY
FACILITY NUMBER: 347004197
VISIT DATE: 03/28/2024
NARRATIVE
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- Forward all of the required documents for a change of administrator in order to make Renilyn Campos the Designated Facility Administrator of Ohana Hospitality.

LPM Richardson asked if reappraisals had been completed prior to the sale and if all the needs and services plans for the residents in care were up to date prior to Renilyn Campos assuming ownership. Agnes Sumagit stated that resident records had been checked by LPA Kevin Gould during their annual inspection and she felt they were up to date.

LPA Viarella will conduct Health and Wellness Checks every 2 weeks while this facility remains unlicensed.

A copy of this report was provided.

Exit interview.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/15/2024 02:40 PM - 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: OHANA HOSPITALITY
FACILITY NUMBER: 347004197

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/30/2024
Section Cited
HSC
1569.19(a)

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1569.19 ... forfeiture by operation of law. A license shall be forfeited by operation of law prior to its expiration date when one of the following occurs: (a) The licensee sells... transfers the facility or facility property....
This requirement was not met as evidenced by:
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The new owner, Renilyn Campos will submit an application for a new license to the Centralized Applications Bureau within 15 days of the date of this visit.
An application for a new license was submitted to CAB. This POC has been cleared as of today.
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Based on interviews and a review of documents, the licensee sold the business on 06/01/23; At that point, the license was forfeited. This posed/poses an immediate risk to the health, saftey and personal rights risk to residents in care.
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2024
LIC809 (FAS) - (06/04)
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