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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002896
Report Date: 08/30/2024
Date Signed: 08/30/2024 11:09:12 AM


Document Has Been Signed on 08/30/2024 11:09 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: 4DATE:
08/30/2024
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Staff- Pius NwaukoniTIME COMPLETED:
11:10 AM
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On 08/30/24, Licensing Program Analysts (LPAs) Cheyenne Ratajczak and Graham Gunby arrived unannounced at the facility to conduct a collateral visit. LPAs met with staff Pius Nwaukoni and explained the purpose of the visit.

LPAs conducted a visit to this facility today to follow up on R1 who was relocated to this facility on 08/29/2024. R1 was relocated due to a Temporary Suspension Order issued at another licensed facility by the Department.

LPAs spoke to R1 who indicated that they adjusting to the facility as best as can be expected with the sudden change.

No deficiencies are cited during today’s visit.

Exit interview conducted and copy of the report 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: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024
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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