<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004197
Report Date: 03/12/2024
Date Signed: 03/12/2024 05:41:04 PM


Document Has Been Signed on 03/12/2024 05:41 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:
03/12/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
04:07 PM
MET WITH:Renilyn CamposTIME COMPLETED:
05:45 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 03/12/24, Licensing Program Analysts (LPAs) Kimberly Viarella and Vincent Moleski made an unannounced case management visit to this facility to conduct health and wellness checks. LPAs identified themselves upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator. LPAs met with Renilyn Campos and a brief interview followed.

During this visit, LPAs requested the following:
LIC 500
LIC 308

LPAs interviewed 3 of the 6 residents present. One was out of the facility, one was sleeping, and the third remaining resident was unresponsive. Of the three interviewed, each stated that they were happy with the care given at this time.

No deficiencies were observed or cited during this visit.

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: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024
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 1