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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701380
Report Date: 03/28/2024
Date Signed: 04/02/2024 05:44:03 PM

Document Has Been Signed on 04/02/2024 05:44 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:OMO'S HOMEFACILITY NUMBER:
392701380
ADMINISTRATOR:OIFOH, PATIENCE OMOZUWAFACILITY TYPE:
735
ADDRESS:14536 SILVER CREEK DRTELEPHONE:
(909) 254-3793
CITY:LATHROPSTATE: CAZIP CODE:
95330
CAPACITY: 4CENSUS: 0DATE:
03/28/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Patience OifohTIME COMPLETED:
01:00 PM
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Announced Prelicensing visit made out to this facility on 03/28/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated representative and Applicant, Patience Oifoh, at this time. A brief interview was conducted with the facility designated Applicant at this time.
It was learned that this facility was also seeking vendorization through Valley Mountain Regional Center (VMRC) to be able to accept and retain up to (4) Level 4I residents at any given time.
Current census was 0 residents.
There will not be any residents under the care of hospice or home health at any time according to statements made by the facility designated Applicant.
Tour of this facility was conducted.
A tour of the facility kitchen area was conducted. Drawers and cabinets were opened and the items enclosed were reviewed at this time. Drawers housing knives and sharps were observed to be locked and made inaccessible to the residents at this time.
Cleaning agents, bleach, and other supplies were observed to be locked and made inaccessible to the residents at this time.
A review of the facility food supply was conducted. A review of the facility's 2-day perishable foods and 7-day nonperishable foods was conducted to make sure that there were sufficient quantities on hand at all times.
Medication cabinet, located in a kitchen cabinet over the counter area, was reviewed. Policies and procedures involving handling, dispensing, and documentation of the resident medications were discussed with the facility Applicant at this time. A review of the facility Medication Administration Record and dispensing log was conducted.
Medication cabinet was observed to be locked and made inaccessible to the residents at this time.
Living room, dining area, and all other areas intended for resident use were observed to furnished and maintained in compliance at this time and able to meet the needs of the residents.
A tour of the resident bedrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2024
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 2
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: OMO'S HOME
FACILITY NUMBER: 392701380
VISIT DATE: 03/28/2024
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A tour of the resident restrooms was conducted.
Hot water temperatures were taken to make sure that they measured within the allowed range of 105-120 degrees at all times.
Laundry area, located in the garage area, was observed to be contain all of the detergents, soaps, and bleach and was properly stored at this time. It was learned that all cleaning and laundry supplies were separately locked and made inaccessible to the residents at all times. LPA observed that the door leading into the garage was locked and made inaccessible to the residents at this time.
Linen closet was reviewed. Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the garage area was conducted.
First aid kits were observed to be present and contained all of the required components at this time.
Fire extinguisher was observed to be placed in the kitchen area and was just recently purchased and found to be in compliance at this time.
A tour of the exterior grounds for this facility was conducted. A review of the facility perimeter fence, side gates, and exits was conducted.

Component III reviewed and completed with the facility Applicant Patience Oifoh.

This facility was found to be in compliance at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
LIC809 (FAS) - (06/04)
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