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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002896
Report Date: 05/24/2023
Date Signed: 05/24/2023 02:26:17 PM


Document Has Been Signed on 05/24/2023 02:26 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 NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



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: 5DATE:
05/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Benedicta Nwaukoni, AdministratorTIME COMPLETED:
02:40 PM
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On 5/23/2023 at 12 PM, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to conduct a Required- 1 Year inspection utilizing the inspection tool. LPA met with staff, Pius Nwaukoni, and explained the purpose of the visit. LPA requested for staff to notify administrator, Benedicta Nwaukoni, of LPA's presence at the facility. Administrator was unable to meet at the facility and gave staff permission to assist LPA during today's visit.

At 12:35 PM, LPA toured the interior and exterior of the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to: residents' bedrooms, bathrooms, common areas, kitchen, backyard, laundry room, and medication cabinet. Bathrooms are clean, sanitary, and in good repair. Toxic and cleaning supplies are locked and is inaccessible to residents in care. LPA observed fire extinguishers, fire detectors, and carbon monoxide present at the facility. Fire extinguisher was last serviced on 07/26/2023. LPA observed food supplies of non-perishable for a minimum of one week and perishable foods for a minimum of two days. First aid kit was completed.

At 1:05 PM, LPA reviewed a total of four (4) residents' files. Four out of four residents' files contain signed Admission Agreements, Identification Sheet, Releases, Preplacement Appraisals, and Resident's Rights. Medications are centrally stored, locked, and appear to be given per doctor order. LPA compared medications to those being given for four (4) residents and found no discrepancies. Facility is correctly using the Medication Administration Records (MAR). LPA reviewed a total of one (1) staff record. Staff has training in medications, first aid and CPR, and other various areas of care provision.

No deficencies cited today.

Exit interview conducted and appeal rights were provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2023
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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