342700381-6-28-2021-27-AS-SRIN-C4HRNE-20210701131012

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700381
Report Date: 06/28/2021
Date Signed: 06/28/2021 11:33:19 AM

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
03/18/2021 and conducted by Evaluator Anthony Tuck

COMPLAINT CONTROL NUMBER: 27-AS-20210318094359

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: 5	DATE:	06/28/2021
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Staff Prince Ehimamiegho		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Food served by facility is not of the quality or quantity to meet the residents' needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Anthony Tuck arrived at facility unannounced on 06/28/2021 and was met by Prince Ehimamiegho. LPA explained the purpose of the visit to deliver findings and conclude the compliant investigation.
The allegation is Food served by facility is not of the quality or quantity to meet the residents' needs.

The initial complaint was opened via televisit due to COVID safety measures on 03/19/2021. LPA conducted interviews with Administrator, 1 staff, 1 witness, and 4 out of 5 residents. LPA learned that resident # 3 is no longer living at the facility. LPA obtained and reviewed requested documents and photographs from the administrator via email. LPA reviewed a copy of the sample menu for the month of March of 2021. LPA reviewed copies of each residents LIC 602. LPA reviewed copy of facility resident roster and staff roster. LPA reviewed photographs of Resident food pantry, refrigerator and freezer. LPA learned from interview with W1 that R1 is being provided plenty of food for each meal being served.

Continued on LIC 9099C...

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony Tuck	TELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021

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

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20210318094359

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: 06/28/2021

NARRATIVE

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Based upon review of documentation, interviews and photographs received, LPA observed the facility to have a wide variety of nutritious, healthy food options available in the facility and provides sufficient amounts of food for each meal to each person in care.

This agency has investigated the allegations listed above. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint. Exit interview was conducted with Staff Prince Ehimamiegho. Copy of the report was provided to Staff Prince Ehimamiegho upon conclusion of the visit.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony Tuck	TELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021

LIC9099 (FAS) - (06/04)

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