<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700381
Report Date: 01/30/2023
Date Signed: 01/30/2023 02:15:38 PM


Document Has Been Signed on 01/30/2023 02:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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: 4DATE:
01/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:36 AM
MET WITH:Justice EhimamieghoTIME COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPAs) Pang Lee and Avelina Martinez arrived at the facility to conduct an unannounced annual inspection on 1/30/2023. LPAs met with Justice Ehimamiegho and explained the purpose of the visit. Administrator Justice Ehimamiegho assisted with today’s visit.

LPAs 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. LPAs observed the facility to be free of odor and clean. LPAs observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present.

The facility has one main Covid-19 screening entry point. The facility has Covid-19 posting throughout the facility. The furniture is spaced six feet apart, and the facility does daily cleaning. The facility has a 30-day supply of PPE. LPAs observed an insufficient supply of food in the facility. The facility has three refrigerators designated for resident food use. One refrigerator was locked, which had very little food and a knife and insulin medication was kept in that fridge. The second resident refrigerator was empty, and the third refrigerator only had two gallons of milk. In addition, the facility water temperature measured at 95 degrees. Moreover, hallway light fixture was not in good repair and is missing a light bulb. Bedroom two and four were missing electric plate covers. The facility smoke and carbon detectors are in good repair, and the fire extinguishers are in good repair. The facility has a first aid kit, and the medications are stored in a locked cabinet. LPAs toured the exterior of the facility. The facility’s exterior fence is not in good repair. The patio canopy is not in good repair, and there are cigarette butts on the grass area. LPAs reviewed two resident files and three staff files. The resident files were up to date, and Staff 1 (S1) does not have a staff file.

Continued...
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


Document Has Been Signed on 02/21/2023 09:52 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 02/02/2023 02:07 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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: 01/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/31/2023
Section Cited

1
2
3
4
5
6
7
87555(b)(26) General Food Service Requirements: The following food service requirements shall apply... Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement was not met as evidence by:
1
2
3
4
5
6
7
Facility staff agrees to buy food for resident in care by 01/31/23. Facility staff agrees to email LPA Lee pictures of food supplies by POC date 01/31/23 by close of bussiness 5:00 PM.
8
9
10
11
12
13
14
Based on observation: The Licensee did not ensure the facility had a 7 and 2 days supplies of non-perishable and perishable food. One of the designated resident refrigerator was empty. The other refrigerator was lock. This pose an immediate health and safety risk to resident in care.
8
9
10
11
12
13
14
Type A
01/31/2023
Section Cited

1
2
3
4
5
6
7
87555(b)(24)General Food Service Requirements: The following food service requirements shall apply...Pesticides and other toxic substances shall not be stored in food storerooms, kitchen areas, or where kitchen equipment or utensils are stored. This requirement was not met as evidence by:
1
2
3
4
5
6
7
Facility staff agrees to remove insulin medicaton out of resident food refridgerator by POC date 01/31/23. Staff agrees to email LPA Lee pictures of new medication storage by POC date 01/31/23 by close of bussiness 5:00 PM.
8
9
10
11
12
13
14
Based on observation and interview Licensee did not ensure insulin medication was stored separately from resident food.
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-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 01/30/2023 02:15 PM - 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
SACRAMENTO AC/SC, 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: 01/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/31/2023
Section Cited

1
2
3
4
5
6
7
1569.269(5) Enumerated rights; severability
Residents of residential care facilities for the elderly shall have all of the following rights: To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment. This requirement was not met evidence by...
1
2
3
4
5
6
7
Facility staff agrees to unlock refrigerator and removed insulin medication and stock the fridge with food. Facility staff will email LPA Lee pictures of unlock fridge and food supplies by POC date 01/31/23 by end of business day 5:00 PM.
8
9
10
11
12
13
14
Based on obervation one of the resident designated food refreigarotor was lock and made inaccessiable to resident in care. This pose an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Type B
01/31/2023
Section Cited

1
2
3
4
5
6
7
87303(e)(2)Maintenance and Operation
Water supplies and plumbing fixtures shall be maintained as follows...Faucets used by residents for personal care such as shaving and grooming shall deliver hot water... This requirement was not met as evidence by:
1
2
3
4
5
6
7
Facility staff agrees to adjust water temperature by POC date 01/31/23. Staff agrees to email LPA Lee facility water temperature log by POC date 01/31/23 by close of business 5:00 PM
8
9
10
11
12
13
14
Based on observation and inspection the licensee did not ensure water temperature did not measure to the require temperature of 105-120. Resident bathroom sink water temperature measured at 95 degrees. This poses a potential health and safety risk to residents 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-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document is an Amendment of Original Document on 02/02/2023 02:04 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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: 01/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2023
Section Cited

1
2
3
4
5
6
7
87303(a)Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times...This requirement was not met evidence by...Based on observation and inspection the licensee did not ensure building and grounds were in good repairs.
1
2
3
4
5
6
7
 Staff agrees to repair all broken fence and remove all hadzard from facility and clean up cigarette butts, repair light fixture and miss plate in resident room 2 and 4. Staff shall email pictures to LPA Lee by POC date 02/10/2023 by end of bussiness day 5 PM.
8
9
10
11
12
13
14
Broken exterior fence, broken canopy blocking the emergency gate, electric plate plugs are missing in room 2 and 4, light bulb is missing in hall way light fixture. This pose a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
Type B
02/23/2023
Section Cited

1
2
3
4
5
6
7
87412(a) Personnel Records: The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This requirement was not met as evidence by: Based on observation and file review, the Licensee did not ensure all staff files were completed.
1
2
3
4
5
6
7
Staff agrees to conduct personal staff file training and creat a staff file for S1 by POC date 02/23/2023. Staff shall email training documents to LPA Lee by POC date 02/23/2023 by end of bussiness day 5 PM.
8
9
10
11
12
13
14
The facility did not have a staff file for Staff 1. This posed a potential health and safety risk to residents 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-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: SUPREME RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 342700381
VISIT DATE: 01/30/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The following documents shall be submitted to LPA Lee by 02/10/2023 by close of business 5:00 PM.
(1) LIC308 Designation of Administrative Responsibility
(2) LIC500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance

As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the 809 D page. An exit interview was conducted, and a copy of these 809 reports, 809 D Page, and Appeals rights were provided to the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5