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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700381
Report Date: 07/06/2026
Date Signed: 07/06/2026 12:01:27 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/18/2026 and conducted by Evaluator Shakaricka Hughes
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260518152352
FACILITY NAME:SUPREME RESIDENTIAL CARE FACILITYFACILITY NUMBER:
342700381
ADMINISTRATOR:STEPHANIE M SIEWEFACILITY TYPE:
740
ADDRESS:8326 SUMMER CREEK CTTELEPHONE:
(916) 895-2787
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 5DATE:
07/06/2026
UNANNOUNCEDTIME BEGAN:
09:04 AM
MET WITH:Administrator: Stephanie SieweTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained injuries due to staff neglect or physical abuse.
Resident was lying on floor for an extended period of time.


INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 07/06/2026, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with the Administrator Stephanie and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 5.

Allegation: Resident sustained injuries due to staff neglect or physical abuse
It was alleged that a resident sustained injuries due staff neglect or physical abuse. This investigation consisted of interviews with facility staff, residents, and records review. On 05/12/2026 LPA Hughes conducted a visit to the facility and interviewed one (1) facility staff who stated that they did not observe any bruising, bedsores, or other injuries on Resident (R1). Staff (S2) stated they were instructed by the Emergency Operator not to reposition or change R1 while awaiting transportation. LPA interviewed two (2) residents who did not express any concerns regarding the care provided by facility staff or report witnessing neglect or physical abuse.

Continuation 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 27-AS-20260518152352
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SUPREME RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 342700381
VISIT DATE: 07/06/2026
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
LPA reviewed physician discharge records for resident (R1), which did not indicate that R1 sustained injuries consistent with physical abuse or neglect while residing at the facility. The records did not indicate bruising, pressure injuries to support the allegation that facility staff caused injuries to R1. Based on the information and evidence obtained during this investigation, there is not enough evidence to corroborate this allegation, therefore the allegation is unsubstantiated.

Allegation: Resident was lying on floor for an extended period of time.

It was alleged that a resident was lying on the floor for an extended period of time. This investigation consisted of interviews with facility staff, and residents in care. On 05/12/2026 LPA Hughes conducted a visit to the facility and interviewed one (1) facility staff who stated that resident (R1) frequently lies on the floor, and staff must redirect the resident to their bed or alternative areas to sit and rest. Staff (S2) stated that they were instructed not to reposition (R1) so the facility waited for Emergency Services, while the resident was laying on the floor. LPA interviewed one (1) residents who stated that they have not observed any residents in the facility lying on the floor for an extended period. Interview with resident (R3) stated that they have observed resident (R1) laying on the floor in their bedroom, stating that staff usually assist the resident back to their bed. On 05/12/2026, LPA attempted to interview resident (R1) but was unable as the resident declined interview. LPA observed resident (R1) lying on their bed, R1 appeared to be clean and unsoiled. There is not enough information or evidence present to corroborate this allegation, therefore the allegation is unsubstantiated.


The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/18/2026 and conducted by Evaluator Shakaricka Hughes
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260518152352

FACILITY NAME:SUPREME RESIDENTIAL CARE FACILITYFACILITY NUMBER:
342700381
ADMINISTRATOR:STEPHANIE M SIEWEFACILITY TYPE:
740
ADDRESS:8326 SUMMER CREEK CTTELEPHONE:
(916) 895-2787
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 5DATE:
07/06/2026
UNANNOUNCEDTIME BEGAN:
09:04 AM
MET WITH:Administrator: Stephanie SieweTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not ensure resident's incontinent needs are being met.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 07/06/2026, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with the Administrator Stephanie and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 5.

Allegation: Staff do not ensure resident's incontinent needs are being met.
It was alleged that staff do not ensure resident’s incontinent needs are met. This investigation consisted of interviews with facility staff, residents, and facility observations. On 05/12/2026 LPA Hughes conducted a visit to the facility and spoke with the facility licensee who stated that residents are routinely showered 2-3 times per week, or more frequently as needed. The licensee stated they were not present when Resident (R1) was transported to by emergency medical services but acknowledged they were aware that R1 was not changed prior to transport. LPA interviewed Staff (S2), who state they are primarily responsible for providing personal care services, including changing residents and ensuring their incontinent needs are being met.

Continuation 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20260518152352
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SUPREME RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 342700381
VISIT DATE: 07/06/2026
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
LPA also interviewed one (1) resident who requires staff assistance with incontinent care, who stated that staff usually assist them with changing when needed. During a visit on 05/12/2026, LPA directly observed two (2) residents whose incontinent care needs were not being met in a timely manner. LPA further observed a strong odor or urine emanating from one resident whose undergarments had reportedly not been changed since the previous night. These observations were consistent with residents not receiving timely incontinent care. Based on the information and evidence obtained this allegation was observed not in compliance with Title 22 regulation 87625(b)(3) as the facility did not ensure residents incontinent needs were being met in a timely manner.


As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with and a copy of the LIC 9099, LIC 9099-D pages and appeal rights were provided to facility.
 
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20260518152352
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SUPREME RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 342700381
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/10/2026
Section Cited
CCR
87625(b)(3)
1
2
3
4
5
6
7
87625 Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.
1
2
3
4
5
6
7
The facility stated the facility has implemented a new schedule of changing residents every 2 hours, and requiring additional staffing during the morning shift, to assist with incontinent care of residents. The facility has requested hospital beds for (3) residents, stating that physician's have
8
9
10
11
12
13
14
This requirement was not met as evidenced by:
Based on facility observations the facility did not ensure incontinent needs were met for two (2) residents in care, as (1) resident had a strong odor of urine, and facility staff stated the residents undergarments had not been changed since the previous night.
8
9
10
11
12
13
14
approved hospital beds for (3) incontinent residents in care. The facility will send LPA a statement of acknowledgement of the regulation cited, and facility processes to ensure resident incontinent needs are being met by 07/10/2026.
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.
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5