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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700381
Report Date: 02/02/2023
Date Signed: 03/08/2023 02:22:06 PM


Document Has Been Signed on 03/08/2023 02:22 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:
02/02/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Justice EhimamieghoTIME COMPLETED:
02:36 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 Analysts (LPAs) Pang Lee and Avelina Martinez arrived at the facility on 02/02/2023 at 1:15 PM to conduct an unannounced Plan of Correction (POC) visit. LPAs met with Sylvia Osei and explained the purpose of the visit. Sylvia stated that she doesn’t work at the facility. LPA Lee asked to speak to the administrator or licensee. Sylvia stated that she will call Stephanie. LPA Lee asked if Justice was in the facility and Sylvia stated, “he’s coming”. After 45 minutes, care staff Stephanie Siewe arrived at the facility. LPA Lee informed Stephanie the purpose of the visit. The purpose of the visit was a Proof of correction (POC) visit to determine if the citation issued on 01/30/23 have been corrected

Based upon this inspection, the LPAs observed the following:
I. Deficiency cited under Title 22 Regulation 87555(b)(26) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee.
II. Deficiency cited under Title 22 Regulation 1569.269(5) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee.
III. Deficiency cited under Title 22 Regulation 87303(e)(2) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee.

During the visit the licensee requested a call with LPM to discuss his concerns. LPM got on the call and heard the licensee and LPAs concerns. The licensee requested for a separate meeting with LPM. During this time, LPM requested LPAs to leave the facility. The LPM advised the licensee that the report will be email to him. Due to the abrupt end of the visit the LPAs was not able to verify the rest of the corrections.
An exit interview was held, and a copy of this report, 809 was given to the facility at the end of the visit. Facility was provided POC cleared letter.



SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2023
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 1