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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700381
Report Date: 01/03/2024
Date Signed: 01/03/2024 11:45:14 AM


Document Has Been Signed on 01/03/2024 11:45 AM - 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:SUPREME RESIDENTIAL CARE FACILITYFACILITY NUMBER:
342700381
ADMINISTRATOR:STEPHANIE SIEWEFACILITY TYPE:
740
ADDRESS:8326 SUMMER CREEK CTTELEPHONE:
(916) 895-2787
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 5DATE:
01/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Justice Ehimamiegho - AdministratorTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced required 1 year annual inspection visit. LPA met with administrator and explained the purpose of the visit. Administrator assisted LPA for inspection visit on today's date.

LPA inspected the physical plant including, but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. This facility is a single story building licensed to serve four (6) non-ambulatory residents and (2) hospice waiver. LPA observed the facility to be free of odor and clean. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. The furniture is spaced six feet apart, and the facility does daily cleaning. LPA observed an insufficient supply of food in the two day perishables; missing vegetables, dairy products, bread, and fruit. The hot water temperature was measured at 110.7*F in kitchen sink and is within the required range of 105-120*F. The temperature inside the facility measured at 75*F which was within the required range of 68-85*F.
The facility smoke and carbon detectors are in good repair. Fire extinguishers last inspected on 2/2/2023. The facility has a first aid kit, and the medications are stored in a locked cabinet. LPA toured the exterior of the facility.

LPA reviewed four resident files and four staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are Fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews.

The following documents shall be submitted to LPA Wallace by 01/17/2024:
LIC 308 Designation of Administrative Responsibility, LIC 500 Personnel Report, Copy of Administrator Certificate, and Proof of Current Liability Insurance.
ruth.wallace@dss.ca.gov

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, see violation cited during this visit.
Exit interview held with administrator. A copy of LIC 809, LIC 809-D, LIC 811 (Confidential Names), and Appeal Rights left at facility.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2024
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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Document Has Been Signed on 01/03/2024 11:45 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)
General Food Service Requirements
(b) The following food service requirements shall apply:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in the facility did not have a two day supply of perishables including dairy products, fresh vegetables, fruit, and bread which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/05/2024
Plan of Correction
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Licensee agreed to purchase groceries during LPA annual inspection visit on 1/3/2024. Licensee purchased dairy products, fresh vegetables, fruit, and bread. POC date is 1/5/2024 and LPA cleared POC on 1/3/2024. No further action required.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2024
LIC809 (FAS) - (06/04)
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