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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002896
Report Date: 04/18/2022
Date Signed: 04/18/2022 10:12:56 AM


Document Has Been Signed on 04/18/2022 10:12 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:MARATHA MANORFACILITY NUMBER:
345002896
ADMINISTRATOR:NWAUKONI, BENEDICTAFACILITY TYPE:
740
ADDRESS:5416 WOODED GLEN PLACETELEPHONE:
(510) 860-2927
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY:6CENSUS: 6DATE:
04/18/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:Benedicta Nwaukoni, AdministratorTIME COMPLETED:
10:08 AM
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Component II completion: Successful

Facility Type: Residential Care Facility for Elderly (RCFE)
Application Type: Change in Ownership (CHOW)
Capacity: 6
Census (if any clients in care): 6
COMP II Participants: Benedicta Nwaukoni, Administrator
Interview Method: Telephone interview

On April 18, 2022, Administrator participated in COMP II. Identification of the Administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Administrator confirmed the understanding of the California Code Title 22 Regulations.

During COMP II, CAB Analyst confirmed Administrator’s understanding of following areas:

1. Facility operation: License type, client/resident populations, and program
2. Admission Policies.
3. Staffing Requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General Provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing Readiness

Exit interview conducted with Administrator. Copy sent via PDF email and Administrator informed to return sign copy by end of business day today.
SUPERVISOR'S NAME: Darla NeeleyTELEPHONE: (916) 651-7817
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: 916-657-2469
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2022
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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