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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700381
Report Date: 01/03/2022
Date Signed: 01/03/2022 11:50:22 AM

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:JUSTICE EHIMAMIEGHOFACILITY TYPE:
740
ADDRESS:8326 SUMMER CREEK CTTELEPHONE:
(916) 895-2787
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 6DATE:
01/03/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:56 AM
MET WITH:Justice EhimamieghoTIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Anthony Tuck Island arrived to conduct an unannounced annual/random inspection on 01/03/2022. LPA met with Justice Ehimamiegho and explained the purpose of the visit. Justice Ehimamiegho is the Administrator and holds certificate #6038919740 that expires on 06/11/2022

This facility is a single story building licensed to serve six (6) non-ambulatory residents and a waiver to service 2 hospice residents. LPA toured the physical plant including but not limited to two resident bedrooms, two resident bathrooms, garage and backyard area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present.

LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at (106) degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers and smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguisher last serviced 01/03/2022. Thermostat observed at (72) degrees Fahrenheit.

LPA observed centrally stored medications, toxins and sharp knives kept locked and inaccessible to clients. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed staff associations to the facility. First aid kit was checked and is complete.

LPA received an updated copy of the certificate of liability insurance during visit. All other documents are current and updated on file.

No Deficiencies were found during today's inspection. Exit interview held with Justice Ehimamiegho and a copy of report given at the conclusion of the visit.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony TuckTELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2022
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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