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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201289
Report Date: 07/30/2024
Date Signed: 07/30/2024 12:59:09 PM


Document Has Been Signed on 07/30/2024 12:59 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:SUPRA HOMESFACILITY NUMBER:
079201289
ADMINISTRATOR:GAUTAM, SUJANFACILITY TYPE:
740
ADDRESS:6224 N ARLINGTON BLVDTELEPHONE:
(318) 243-5254
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY:6CENSUS: 3DATE:
07/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:URMILA PARAJULI, CAREGIVERTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced 1-year required visit on 7/30/2024 at 9:50am. LPA met and started tour with Caregiver, Urmila Parajuli and Pratiksha Kharel. Administrator, Sujan Gautam arrived at 10:15am and completed the tour with LPA. The Administrator currently holds a certificate (#7021173740) that expires on 12/05/2025. The facility’s fire clearance was approved for 6 clients, 4 non-ambulatory and 2 ambulatory.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Hot water temperature in the shared residents’ bathroom was measured at 105 degree Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 6/13/2023. Emergency Disaster Plan was last posted on 07/30/2024. First aid kit was observed to be complete.


Report continues on 809C.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: SUPRA HOMES
FACILITY NUMBER: 079201289
VISIT DATE: 07/30/2024
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Continue from LIC809

LPA reviewed staff record 3 of 3 staff have criminal record clearance or a criminal record exemption and 2 of 3 staff holds a current first aid certificate. LPA reviewed 3 resident' files which are complete.

The following forms to be updated and submitted to CCL by 08/06/2024:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 610E Emergency Disaster Plan
Copy of Administrator Certificate


Exit interview conducted, and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC809 (FAS) - (06/04)
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