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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004197
Report Date: 11/20/2023
Date Signed: 11/20/2023 10:49:46 AM


Document Has Been Signed on 11/20/2023 10:49 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 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: 4DATE:
11/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Renilyn CamposTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with Renilyn Campos and explained the purpose of the visit.

LPA Moleski spoke with Campos over the phone on 11/6/23. During this phone call, Campos said that a resident (R1) had died over the weekend. LPA Moleski advised Campos to include all pertinent information in a death report.

LPA Moleski spoke with Campos over the phone on 11/15/23. Campos said R1 was taken to a hospital on 11/4/23 and died afterward. Campos said she was contacted by a mortuary on 11/4/23 informing her that R1 had died.

The Community Care Licensing Division (CCLD) received a death report for R1 on 11/17/23, 11 days after LPA Moleski was originally contacted about the death of R1 and 13 days after the death of R1.

This facility is being cited per 22 CCR Section 87211(a)(1)(A). An exit interview was held with Campos. Appeal rights and a copy of this report were left with Campos.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2023
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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Document Has Been Signed on 11/20/2023 10:49 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
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: 11/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/22/2023
Section Cited
CCR
87211(a)(1)(A)

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"(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:

(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

(A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility."

This requirement was not met as evidenced by:
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Administrator agrees to read and review the reporting requirements and further agrees to write a signed statement acknowledging the requirements, and stating that they will be adhered to in the future. Administrator wrote and signed this statement during this visit. This POC will be cleared.
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Based on interview and record review, a death report was not furnished to CCLD within seven days of the death of R1, which poses a potential health and safety risk.
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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: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2023
LIC809 (FAS) - (06/04)
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