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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002918
Report Date: 10/01/2024
Date Signed: 10/01/2024 04:02:00 PM

Document Has Been Signed on 10/01/2024 04:02 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ADONAI CARES FOR ELDERLYFACILITY NUMBER:
345002918
ADMINISTRATOR/
DIRECTOR:
SAMUELS, OLAWUMIFACILITY TYPE:
740
ADDRESS:5532 HONOR PARKWAYTELEPHONE:
(310) 272-3318
CITY:SACRAMENTOSTATE: CAZIP CODE:
95835
CAPACITY: 6CENSUS: 4DATE:
10/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:04 PM
MET WITH:Ola Samuels, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On October 1, 2024 at Licensing Program Analyst (LPA) De Anna Williams-Lyons arrived unannounced to conducted an Annual Inspection of the facility to ensure compliance with Title 22 regulations. LPA Lyons met with Ola Samuels, Licensee, who assisted LPA in today’s inspection. The Administrator certificate expires 12/13/2024. The current census is 4 The facilities Administrator’s Certificate, Emergency Disaster Plan, Resident’s Rights and Facility Sketch was available for viewing. The room temperature was 67 degrees F.

This is a one story home with 4 bedrooms and 3 bathrooms.

LPA inspected the interior and the exterior of the facility including the common living spaces, the resident bedrooms and bathrooms and kitchen. In the kitchen area, cabinets and drawers were reviewed. Knives and sharp objects were reviewed to make sure that they were locked and made inaccessible to the residents at all times. LPA observed there to be a sufficient amount of 2-day perishable and 7-day non-perishable food. Hot water temperatures were taken and measured at 105 degrees F. There’s appropriate lighting throughout the home.

Living rooms, dining room, and areas designated for resident use were toured. Furniture and furnishings were observed to be sufficient and in good repair. Resident bedrooms and bathrooms were toured. There are 4 Bedrooms. All rooms had the required items of furniture. Window screens were on and in good repair. Bathrooms were clean, sanitary and odorless and consisted of grab bars and non-skid mats. The sink, toilet, bathtub and shower operate properly. The facility has a sufficient supply of linens, towels, bedding, etc. for residents in care. Washer and dryer was present and operating properly. Toxic substances, laundry and cleaning supplies were inaccessible.

To continue see 809-C...

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE: DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ADONAI CARES FOR ELDERLY
FACILITY NUMBER: 345002918
VISIT DATE: 10/01/2024
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First aid kit was present and included the required scissors, tweezers, thermometer and guide. Fire alarms, smoke alarms, and carbon monoxide detectors operate properly. Fire extinguishers are maintained and ready for emergency use. LPA inspected the exterior grounds of this facility. LPA toured the exterior grounds. There are no bodies of water on the premises. The perimeter fence, side gates, and latches were in good repair. Passageways are free of obstruction and potential hazards

There’s a drawer for resident’s medication. Medication cabinet was locked. The facility Medication Administration Record was reviewed as well as the dispensing log. All current and up to date.

LPA reviewed 2 resident files and 1 staff files. Resident's Records reviewed indicated emergency contacts, Assessments, Admission Agreements and Physician's Reports were all current and up to date. Staff records reviewed revealed current First Aid & CPR certificates, Health Screenings, Emergency Contacts, Criminal Record Clearances were all up to date and the facility is conducting staff training as required.

File review reveals all documents are in the regional facility file.

LPA and Ola conducted the Inspection Tool with no issues or concerns. The facility has had 2 residents with Covid-19 since the last annual inspection. The licensee is following her Infection Control Plan as required.

In the areas that were evaluated, no deficiencies were observed.

The administrator shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610D the Emergency Disaster Plan, and copy of current Liability Insurance to update the facility file. Administrator shall submit the listed documents to Licensingno later than November 1, 2024. Licensee submitted the document at this visit,

An exit interview was conducted and a copy of this report was given to Ola.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC809 (FAS) - (06/04)
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