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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004197
Report Date: 05/07/2024
Date Signed: 05/07/2024 02:06:33 PM


Document Has Been Signed on 05/07/2024 02:06 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: 5DATE:
05/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Renilyn CamposTIME COMPLETED:
02:15 PM
NARRATIVE
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On 05/07/24, Licensing Program Analyst, Kimberly Viarella, made an unannounced visit to the facility to conduct an annual inspection. 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 and a brief interview followed.

DFA Certificate Number: 7015087740 and expires on 02/22/26.

The facility tour began in the kitchen. All knives and sharps were locked and inaccessible to residents in care at the time. LPA observed an adequate food supply for 7 day non-perishable and 2 day non-perishable. All food items in the refrigerator were stored and dated appropriately. The DFA had posted a menu calendar for residents and staff to access. LPA checked the dates printed of a sample of items from the refrigerator and pantry to ensure they had not expired.

LPA observed cleaning supplies in a cabinet under the sink and toxic hygiene items in another cabinet in the kitchen that were accessible to residents in care. Additional cleaning supplies were observed in the cabinet under the sink in the master bathroom. Staff immediately installed magnetic locks and secured all of these items returning the facility to compliance.

The (2) fire extinguishers were last inspected on 08/31/23 by Jorgensen Co.

LPA observed the following signs posted: Administrator certification, facility sketch, See Something Say Something poster, and Visiting Hours.

LPA then inspected the 5 resident bedrooms. LPA observed all the required furniture, furnishings and lighting required to be in compliance.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024
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 5


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: 05/07/2024
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The facility had 4 bathrooms, 2 for residents and 2 for staff. LPA observed soap dispensers and paper towels in resident bathrooms. LPA observed that the full bath also had the bath mats and grab bars required to be incompliance. The LPA measured the hot water temperature and found it to be 114.4 degrees Fahrenheit and in compliance at the preset time.

LPA observed that the great room, dining room, and office all had the furniture, furnishing and lighting to accommodate the residents in care at this time.

The Centrally Stored Medication Record was reviewed and compared with medications on hand. Medication administration, storage, and destruction procedures were reviewed with the DFA. LPA inspected the First Aid kit and it contained all of the required components to be in compliance at the present time.

LPA toured the exterior of the facility and observed all screens and gutters in tact and a patio area with furniture for residents to enjoy. There were no bodies of water present. There was one locked shed and the LPA observed that it contained stored furniture and other household items.

LPA reviewed 3 staff files and 3 resident files. The DFA could not produce proof of training for 2 of the 3 files reviewed. LPA observed that 1 out of 3 resident files was missing its required updated LIC 602 and reappraisal.

According to the California Code of regulations, Title 22, the deficiencies that were observed today were cited in the LIC 809 D page.

A copy of this report was provided along with APPEAL RIGHTS.

Exit interview.

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

DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 05/07/2024 02:06 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: 05/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and interview, the licensee did not comply with the section cited above in 3 out of 3 locations when the LPA saw Lysol spray, Cascade, mouth wash, and fabric and leather adhesive in the kitchen and master bathroom cabinets which poses(ed) an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2024
Plan of Correction
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The Designated Facility Administrator had staff install magnetic locks on the kitchen cabinets and will submit a photo to kimberly.viarella@dss.ca.gov of the toxic items in the bathroom relocated to the locked cabinet in the bathroom by the close of business tomorrow 5/08/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 05/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 05/07/2024 02:06 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: 05/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 2 out 3 staff files reviewed. They did not contain documentation of required annual training. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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The Designated Facility Administrator will ensure staff training is complete and documented by 5/31/24 and will email documentation tokimberly.viarella@dss.ca.gov by 5/31/24.
Type B
Section Cited
CCR
87705(c)(6)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on 1 out of 3 files reviewed, the Licensee did not comply withe the above regulation when an annual reappraisal was not completed for a dementia care resident. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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The Designated Facility Administrator (DFA) will conduct file review and will ensure that any necessary medical appointments are made/completed so that LIC 602s and Needs and Assessments plans may be updated. The DFA will submit a list of their residents with the dates of their physicians' appointments to kimberly.viarella@dss.ca.gov by 5/31/24.
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: 05/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5