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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004197
Report Date: 03/29/2024
Date Signed: 03/29/2024 02:40:28 PM


Document Has Been Signed on 03/29/2024 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:
03/29/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Renilyn CamposTIME COMPLETED:
03:00 PM
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On 03/29/24 Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced trip to this facility to conduct a case management visit. The LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator (DFA). LPA met with Renilyn Campos.

LPA briefly toured the facility. LPA observed 3 residents in the living room watching TV, 1 resident sleeping, and 2 occupied in their rooms. LPA observed 1 care staff assisting a resident, and the other preparing lunch.

LPA interviewed the Renilyn Campos, and presented a copy of the Notice to Operate in Violation of Law (NOVL) along with a Letter of Forfeiture. Renilyn Campos provided this LPA with the facility license.

No deficiencies were observed or cited during today's 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: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2024
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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