342700381-12-29-2021-27-AS-KHOS-CACLLL-20220104075119

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700381
Report Date: 12/29/2021
Date Signed: 12/29/2021 12:07:39 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-20211206153726

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:	12/29/2021
		UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	staff Stephanie Siewe		TIME COMPLETED:	12:08 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility did not provide resident with a comfortable mattress

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Anthony Tuck arrived at the facility unannounced and was met by Staff Stephanie Siewe on 12/29/2022. LPA explained the purpose of today's visit to conclude the complaint investigation and review findings for the allegation listed above. Staff contacted Licensee Justice Ehimaniegho via telephone to be present during visit. Licensee arrived shortly after called and met with LPA.

LPA conducted interviews with R4 and R2 and S1 on 12/10/2021 during the initial investigation. LPA learned that the facility replaced the bed mattress for both R2 and R4 with spare mattresses that were never used. LPA inspected the condition of the bed mattress for R2 and R4. LPA did not find any issues with the condition of either mattress. LPA observed both mattresses to be basic standard mattresses in new condition.

This agency has investigated the allegation 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 Justice Ehimaniegho, a copy of the report was left with the facility upon exit. No deficiencies were cited during this investigation.

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: 12/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2021

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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