342700381-1-3-2022-27-AS-KHOS-CACM4P-20220104081703

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700381
Report Date: 01/03/2022
Date Signed: 01/03/2022 03:19:31 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
12/06/2021 and conducted by Evaluator Anthony Tuck

COMPLAINT CONTROL NUMBER: 27-AS-20211206143822

FACILITY NAME:	SUPREME RESIDENTIAL CARE FACILITY		FACILITY NUMBER:	342700381
ADMINISTRATOR:	JUSTICE EHIMAMIEGHO		FACILITY TYPE:	740
ADDRESS:	8326 SUMMER CREEK CT		TELEPHONE:	(916) 895-2787
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95828
CAPACITY:	6	CENSUS: 6	DATE:	01/03/2022
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Justice Ehimamiegho		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Food services are inadequate.
Facility is not properly maintained.
Facility is unsanitary.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Anthony Tuck arrived at the facility unannounced and was met by Staff Prince Ehimaniegho on 01/03/2021. LPA explained the purpose of today's visit to conclude the complaint investigation and review findings for the allegation listed above.

LPA conducted interviews with R1, R2, R3, R4, R5, and R6 and S1 on 12/10/2021 at the facility during the initial investigation. LPA learned that 4 out of 6 residents were unhappy with the quality of certain meals being served at the facility. LPA observed R6 during an interview to have trouble remembering what meals he had. LPA attempted to interview R5. R5 stated that she did not want to be interviewed and had no complaints. LPA observed several light fixtures either missing bulbs or had bulbs that were burnt out during the investigation. LPA observed the shower in the master bedroom that is shared by R3 and R2. LPA discovered lime and calcium build up on the shower floor. LPA obtained photographs of discovered lighting issues and unsanitary shower floor. LPA observed and obtained photographs of food kept in refrigerator, freezer and pantry, LPA obtained copy of weekly menu. LPA discovered that the facility has several packs of frozen hot-dogs in the freezer and fridge after learning that hot-dogs are not on the weekly food menu.
Continued on LIC 9099C...

Substantiated

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: 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.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20211206143822

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: 01/03/2022

NARRATIVE

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Based upon observation of food kept in the facility and interviews with 4 out of 6 residents, the facility is not following the weekly menu.

The preponderance of evidence standard has been met, therefore the above allegations are found to be
substantiated. The following deficiency was observed (see LIC 9099-D) and cited from the California Code of regulations Title 22. Failure to correct the deficiencies may result in civil penalties. Appeal rights were provided. Exit interview was conducted with Justice Ehimaniegho . LPA generated the report for the staff to sign. A copy of the report LIC 9099, LIC 9099C, LIC 9099-D, and appeal rights were provided upon exit.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony Tuck	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20211206143822

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/03/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/10/2022 Section Cited CCR 87555(a)	1 2 3 4 5 6 7	87555(a) General Food Service Requirements (a)The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council… This was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to remove all food items that are not part of the weekly menu and update the weekly food menu to include new meal selections to be served weekly and special meals to be served on occasion. Licensee will send a copy of updated weekly food menu to CCLD by POC due date.
	8 9 10 11 12 13 14	Based upon interviews with residents, staff, documents, and observation, the licensee did not ensure that the weekly food menu was being followed by staff food items that were not on the weekly menu were found in the fridge and freezer and being served to residents. This poses a potential health and safety risk to persons in care.	8 9 10 11 12 13 14
Type B 01/10/2022 Section Cited CCR 87303(d)	1 2 3 4 5 6 7	(d)There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility. This was not met as evidenced by:	1 2 3 4 5 6 7	Licensee has already replaced or repaired all light fixtures in the facility. Licensee agrees to create a schedule for maintenance repairs to be checked at the facility on a weekly basis. Licensee will send a copy of the maintenance schedule to CCLD by POC due date.
	8 9 10 11 12 13 14	Based on interviews with residents and observations, the Licensee failed to ensure that the facility had sufficient lamps or lighting in each room. This poses a potential health and safety risk to persons in care.	8 9 10 11 12 13 14

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: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony Tuck	TELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20211206143822

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/03/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/10/2022 Section Cited CCR 87303(a)(1)	1 2 3 4 5 6 7	87303(a)(1) Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times… (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to ensure that staff are maintaining a clean, safe and sanitary facility and ensure that resident bathroom floors and surface's are kept clean and free from calcium and lime build up. Licensee will create an additional duty list for staff to complete while conducting daily activities at the facility.
	8 9 10 11 12 13 14	Based on interviews with residents and observations, the Licensee failed to ensure that floor surfaces in bathrooms were maintained to be kept clean and safe and sanitary. This poses a potential health and safety risk to persons in care.	8 9 10 11 12 13 14	Licensee will submit a copy of the new staff daily activity schedule to CCLD by POC due date.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony Tuck	TELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2022

LIC9099 (FAS) - (06/04)

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