342700381-1-24-2025-27-AS-VMOI-DD8STF-20250124130927

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700381
Report Date: 01/24/2025
Date Signed: 01/24/2025 01:09:35 PM

Document Has Been Signed on 01/24/2025 01:09 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	SUPREME RESIDENTIAL CARE FACILITY		FACILITY NUMBER:	342700381
ADMINISTRATOR/ DIRECTOR:	STEPHANIE M SIEWE		FACILITY TYPE:	740
ADDRESS:	8326 SUMMER CREEK CT		TELEPHONE:	(916) 895-2787
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95828
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	01/24/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Justice Ehimamiegho		TIME VISIT/ INSPECTION COMPLETED:	01:15 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 (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with licensee Justice Ehimamiegho and explained the purpose of the visit. LPA Moleski reviewed four resident files (R1-R4) and three staff files (S1-S3). LPA Moleski observed in R3's file three incident reports dating between 6/27/24 and 8/28/24 describing elopements by R3 wherein he was unsupervised in the community. An incident report dated 6/27/24 indicated that R3 was walking around in the backyard around 8 a.m., but when staff checked on him he had evidently left the property through a rear gate. Staff tried to find R3, but could not, so they called 911, according to the incident report. R3 was later found around 8:36 a.m. A second incident report dated 7/01/24 indicated that R3 left the facility through the front door around 9 a.m. and could not be redirected. Staff notified the licensee, who looked through the neighborhood, but could not find R3, according to the incident report. 911 was called, but at the time the incident report was written, R3 had not been found. LPA Moleski reviewed ongoing progress notes for R3 and observed a note dated 7/2/24 that indicated R3 was brought back to the facility by police on 7/2/24 around 7 a.m. LPA Moleski reviewed an after-visit summary from a hospital visit on 8/27/24, which showed R3 was diagnosed with acute psychosis. A third incident report dated 8/28/24 indicated that R3 became irritable and broke the facility television without apparent cause. Later in the day, around 4 p.m., R3 broke a bathroom window and left the facility through the window, according to the incident report. Staff called 911, but a neighbor notified staff that R3 was found in their backyard. R3 is diagnosed with mild cognitive impairment, and is non-ambulatory, according to R3's LIC 602, dated 11/15/23. R3 suffers from confusion and disorientation, and is not able to independently transfer, according to the LIC 602. R3 also has a history of seizures. LPA Moleski asked Ehimamiegho if he felt it is safe for R3 to be in the community independently. Ehimamiegho said that R3 would not be entirely safe, as R3 does require care, and R3 may also be unable to remember how to return to the facility if gone for too long. [continued on 809-C]

Stephen Richardson	TELEPHONE: (916) 263-4746
Vincent Moleski	TELEPHONE: (559) 365-5294
	DATE: 01/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/24/2025

NARRATIVE

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Upon arrival, LPA Moleski observed a noticeable odor of urine in the facility. While reviewing facility records, LPA Moleski observed staff cleaning bedding and removing diapers from resident rooms. While touring this facility, LPA Moleski observed a noticeable odor of urine remaining in R1 and R4's shared room.

LPA Moleski toured the facility with Ehimamiegho and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 73 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 105 degrees Fahrenheit, which is within the required range of 105 and 120 degrees.

LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked cabinet for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives.

LPA Moleski interviewed one staff member (S1) and one resident (R2).

This facility is hereby cited per HSC Section 1569.312(d) and 22 CCR Section 87625(b)(3). An exit interview was conducted and a copy of this report was left with Ehimamiegho.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 01/24/2025 01:09 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 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: 01/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

"Every facility required to be licensed under this chapter shall provide at least the following basic services: ... Being aware of the resident's general whereabouts..." This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, R3 eloped three times between June and August 2024, during which periods of time R3's whereabouts were unknown, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/25/2025
	Plan of Correction
1 2 3 4	Licensee informed LPA Moleski that staffing schedules have already been adjusted in order to allow a staff member to follow R3 if he elopes from the facility. LPA Moleski reviewed this facility's staffing plan and observed corrections have been made. This POC will be cleared. vincent.moleski@dss.ca.gov

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Stephen Richardson	TELEPHONE: (916) 263-4746
Vincent Moleski	TELEPHONE: (559) 365-5294
	DATE: 01/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 01/24/2025 01:09 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 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: 01/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the facility presented odors from incontinence, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/31/2025
	Plan of Correction
1 2 3 4	Licensee agrees to provide LPA Moleski with a written plan outlining continence care and cleaning schedules by POC due date. vincent.moleski@dss.ca.gov

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Stephen Richardson	TELEPHONE: (916) 263-4746
Vincent Moleski	TELEPHONE: (559) 365-5294
	DATE: 01/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025

LIC809 (FAS) - (06/04)

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