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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002896
Report Date: 04/03/2024
Date Signed: 04/03/2024 11:19:42 AM


Document Has Been Signed on 04/03/2024 11:19 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 3DATE:
04/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Staff- Pius NwaukoniTIME COMPLETED:
11:25 AM
NARRATIVE
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On 04/03/24 at 9 AM Licensing Program Analyst (LPA) Cheyenne Ratajczak 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.

LPA and Staff conducted a tour of the interior and exterior of the facility. Areas toured include but not limited to five (5) resident bedrooms, three (3) bathrooms, kitchen, common areas, and storage area. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed food supplies of non-perishables for a minimum of seven (7) days and perishable foods for a minimum of two (2) days. Toxins and cleaning supplies are locked and inaccessible to residents in care. Hot water temperature was measured at 108.2 degrees Fahrenheit at the bathroom sink, which is within the required range of 105 to 120 degrees. The temperature in the facility was 70 degrees. First aid kit was completed. LPA observed fire detectors and carbon monoxide detectors to be operable. LPA observed the fire extinguisher, located in the kitchen and hallways, was last inspected on 09/25/2023.

LPA conducted a file review of one (1) personnel and three (3) residents records. Personnel file was incomplete, the missing document was at the facility but inaccessible to staff and LPA.

LPA completed the full care tool and deficiencies was observed. Please see LIC 809-D.

Exit interview conducted and copy of the report and appeal rights was left at the facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
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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Document Has Been Signed on 04/03/2024 11:19 AM - 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: MARATHA MANOR
FACILITY NUMBER: 345002896

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87755(c)
87755 Inspection Authority of the Licensing Agency
(c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary for copying.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in one personnel file was incomplete with documents that were at the facility but inaccessible to LPA upon request which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2024
Plan of Correction
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Licensee is to submit a statement of understanding to LPA that all documents should be made avaible to staff if Administrator is unavaible to make it to the facility during inspections.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
LIC809 (FAS) - (06/04)
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