342700381-5-13-2021-27-AS-CACL-C36KPC-20210519080433

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700381
Report Date: 05/13/2021
Date Signed: 05/13/2021 02:24:04 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/19/2020 and conducted by Evaluator Anthony Tuck

COMPLAINT CONTROL NUMBER: 27-AS-20201019090257

FACILITY NAME:	SUPREME RESIDENTIAL CARE FACILITY		FACILITY NUMBER:	342700381
ADMINISTRATOR:	JOHNSON, PRINCESS		FACILITY TYPE:	740
ADDRESS:	8326 SUMMER CREEK CT		TELEPHONE:	(916) 821-9723
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95828
CAPACITY:	6	CENSUS: 4	DATE:	05/13/2021
		UNANNOUNCED	TIME BEGAN:	02:02 PM
MET WITH:	Licensee Justice Ehimamiegho		TIME COMPLETED:	02:23 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff member failed to assist resident with toileting needs

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Anthony Tuck contacted Licensee Justice Ehimamiegho via telephone due to COVID 19 Pandemic safety measures to conclude complaint investigation and deliver findings.

During the investigation, LPA conducted interviews with Licensee, conservator (CFR), S1, S2, S3, S4, and R2.
LPA did not contact S5 after learning that S5 was out of the country at this time. LPA learned that only R2 was still living in the facility during the time that R1 was in the facility. No other residents were available to be contacted during this investigation. LPA made 3 total attempts to contact RP. LPA was successful at reaching RP on third attempt. LPA attempted to contact Telecare Clinical Director and did not receive a call back. LPA contacted Telecare Services and learned that the caseworker was no longer with the organization. LPA reviewed copy of R1's admission agreement, pre appraisal, LIC 602, resident logs recorded by staff from 06/01/2020 to 10/16/2020, copies of past incident reports, hospital after visit summary dated 07/28/2020, copy of medications list from MAR, copy of patient discharge instructions dated 08/01/2020.
Continued on LIC 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (209) 242-5200
LICENSING EVALUATOR NAME: Anthony Tuck	TELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 27-AS-20201019090257

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SUPREME RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 342700381
	VISIT DATE: 05/13/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Based on interviews, and documentation reviewed from the facility, the Department (CCLD) has found the
allegation of the Facility staff member failed to assist resident with toileting needs, Unsubstantiated. A finding that the
complaint allegation(s) is UNSUBSTANTIATED means that although the allegation(s) may have happened or
is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred.
An exit interview was conducted with Licensee via telephone and a copy of 9099, 9099-C, and 811(Confidential Names) was provided to Licensee via email, an electronic email read receipt confirms receiving these documents. Licensee will sign 9099, 9099-C's and send back electronic email to LPA.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (209) 242-5200
LICENSING EVALUATOR NAME: Anthony Tuck	TELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2