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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
347004197
Report Date:
07/16/2024
Date Signed:
07/16/2024 01:25:10 PM
Document Has Been Signed on
07/16/2024 01:25 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 HOSPITALITY
FACILITY NUMBER:
347004197
ADMINISTRATOR:
AGNES SUMAGIT
FACILITY TYPE:
740
ADDRESS:
5117 HEATHER RANCH WAY
TELEPHONE:
(916) 534-7707
CITY:
RANCHO CORDOVA
STATE:
CA
ZIP CODE:
95742
CAPACITY:
6
CENSUS:
0
DATE:
07/16/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
01:00 PM
MET WITH:
Franklin Campos
TIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Vincent Moleski and obudsman Ron Carrera arrived unannounced to conduct a case management visit. LPA Moleski and Carrera met with staff member Franklin Campos and explained the purpose of the visit.
LPA Moleski and Carrera intended to check on a resident. LPA Moleski and Carrera were informed by Campos that the resident (R1) had moved recently. LPA Moleski and Carrera interviewed Campos.
No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Campos.
SUPERVISOR'S NAME:
Stephen Richardson
TELEPHONE:
(916) 263-4746
LICENSING EVALUATOR NAME:
Vincent Moleski
TELEPHONE:
(559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE:
07/16/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/16/2024
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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