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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004197
Report Date: 04/21/2023
Date Signed: 04/21/2023 03:38:05 PM


Document Has Been Signed on 04/21/2023 03:38 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:
04/21/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Agnes SumagitTIME COMPLETED:
04:00 PM
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On 4/21/23 at 3:00pm Licensing Program Analysts (LPAs) Kevin Gould and Brandon Panariello conducted an unannounced POC inspection at Ohana Hospitality. LPAs met with Licensee Agnes Sumagit and reviewed POC documents.

LPAs verified all POC documents to be complete and met the requirements of the plan of correction. LPAs generated POC clearance letters and provided them to the licensee.

Per California Code of Regulations, Title 22, there were no deficiencies observed or cited during today's inspection.

Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023
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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