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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002896
Report Date: 04/26/2022
Date Signed: 04/27/2022 08:25:39 AM


Document Has Been Signed on 04/27/2022 08:25 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926



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:
04/26/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Benedicta Nwaukoni, AdministratorTIME COMPLETED:
03:40 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) Jacob Williams arrived at the facility announced on 4/26/2022 to conduct a Pre-licensing referencing the infection control domain. LPA met with Administrator Benedicta Nwaukoni and explained the purpose of the visit. Prior to initiating the pre-licensing inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

LPA toured the interior and exterior of the facility together with Administrator. Areas toured include front room, living room, five (5) resident bedrooms, three (3) bathrooms, two (2) staff rooms, kitchen, laundry area, and backyard. Outdoors was clean, with adequate shading. Indoors has the requisite rooms for activity/den/dining. There are locked cabinets for personnel and client records. Facility has a first Aid kit and centrally stored locked cabinet for medication. Hot water temperature at 114*f. Smoke detectors functional. Fire extinguisher serviced. Toxins and chemicals are appropriately locked in a cabinet. No hazardous debris noted.

Facility currently has six residents as it is operating as Maranatha Manor, undergoing change of ownership.

Component III review completed.

Facility is in significant compliance
License pending approval.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob WilliamsTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2022
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