Supreme Residential Care Facility

Type of visit: POC

Licensing Program Analysts (LPAs) Pang Lee and Avelina Martinez arrived at the facility on 02/02/2023 at 1:15 PM to conduct an unannounced Plan of Correction (POC) visit. LPAs met with Sylvia Osei and explained the purpose of the visit. Sylvia stated that she doesn’t work at the facility. LPA Lee asked to speak to the administrator or licensee. Sylvia stated that she will call Stephanie. LPA Lee asked if Justice was in the facility and Sylvia stated, “he’s coming”. After 45 minutes, care staff Stephanie Siewe arrived at the facility. LPA Lee informed Stephanie the purpose of the visit. The purpose of the visit was a Proof of correction (POC) visit to determine if the citation issued on 01/30/23 have been corrected Based upon this inspection, the LPAs observed the following: I. Deficiency cited under Title 22 Regulation 87555(b)(26) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee. II. Deficiency cited under Title 22 Regulation 1569.269(5) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee. III. Deficiency cited under Title 22 Regulation 87303(e)(2) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee. During the visit the licensee requested a call with LPM to discuss his concerns. LPM got on the call and heard the licensee and LPAs concerns. The licensee requested for a separate meeting with LPM. During this time, LPM requested LPAs to leave the facility. The LPM advised the licensee that the report will be email to him. Due to the abrupt end of the visit the LPAs was not able to verify the rest of the corrections. An exit interview was held, and a copy of this report, 809 was given to the facility at the end of the visit. Facility was provided POC cleared letter.the state’s words, verbatim · CDSS document, Feb 2, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPAs) Pang Lee and Avelina Martinez arrived at the facility to conduct an unannounced annual inspection on 1/30/2023. LPAs met with Justice Ehimamiegho and explained the purpose of the visit. Administrator Justice Ehimamiegho assisted with today’s visit. LPAs inspected the physical plant including, but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. This facility is a single story building licensed to serve four (6) non-ambulatory residents and (2) hospice waiver. LPAs observed the facility to be free of odor and clean. LPAs observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. The facility has one main Covid-19 screening entry point. The facility has Covid-19 posting throughout the facility. The furniture is spaced six feet apart, and the facility does daily cleaning. The facility has a 30-day supply of PPE. LPAs observed an insufficient supply of food in the facility. The facility has three refrigerators designated for resident food use. One refrigerator was locked, which had very little food and a knife and insulin medication was kept in that fridge. The second resident refrigerator was empty, and the third refrigerator only had two gallons of milk. In addition, the facility water temperature measured at 95 degrees. Moreover, hallway light fixture was not in good repair and is missing a light bulb. Bedroom two and four were missing electric plate covers. The facility smoke and carbon detectors are in good repair, and the fire extinguishers are in good repair. The facility has a first aid kit, and the medications are stored in a locked cabinet. LPAs toured the exterior of the facility. The facility’s exterior fence is not in good repair. The patio canopy is not in good repair, and there are cigarette butts on the grass area. LPAs reviewed two resident files and three staff files. The resident files were up to date, and Staff 1 (S1) does not have a staff file. Continued... The following documents shall be submitted to LPA Lee by 02/10/2023 by close of business 5:00 PM. (1) LIC308 Designation of Administrative Responsibility (2) LIC500 Personnel Report (3) Copy of Administrator Certificate (4) LIC610 Emergency Disaster Plan (5) Proof of Current Liability Insurance As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the 809 D page. An exit interview was conducted, and a copy of these 809 reports, 809 D Page, and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Jan 30, 2023

From the deficiency page — Deficiency type: Type A · Plan of correction due date: Jan 31, 2023

87555(b)(26) General Food Service Requirements: The following food service requirements shall apply... Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement was not met as evidence by: Based on observation: The Licensee did not ensure the facility had a 7 and 2 days supplies of non-perishable and perishable food. One of the designated resident refrigerator was empty. The other refrigerator was lock. This pose an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Jan 30, 2023

From the deficiency page — Deficiency type: Type A · Plan of correction due date: Jan 31, 2023

87555(b)(24)General Food Service Requirements: The following food service requirements shall apply...Pesticides and other toxic substances shall not be stored in food storerooms, kitchen areas, or where kitchen equipment or utensils are stored. This requirement was not met as evidence by: Based on observation and interview Licensee did not ensure insulin medication was stored separately from resident food.the state’s words, verbatim · CDSS document, Jan 30, 2023

From the deficiency page — Deficiency type: Type A · Plan of correction due date: Jan 31, 2023

1569.269(5) Enumerated rights; severability Residents of residential care facilities for the elderly shall have all of the following rights: To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment. This requirement was not met evidence by... Based on obervation one of the resident designated food refreigarotor was lock and made inaccessiable to resident in care. This pose an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 30, 2023

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Jan 31, 2023

87303(e)(2)Maintenance and Operation Water supplies and plumbing fixtures shall be maintained as follows...Faucets used by residents for personal care such as shaving and grooming shall deliver hot water... This requirement was not met as evidence by: Based on observation and inspection the licensee did not ensure water temperature did not measure to the require temperature of 105-120. Resident bathroom sink water temperature measured at 95 degrees. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 30, 2023

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Feb 10, 2023

87303(a)Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times...This requirement was not met evidence by...Based on observation and inspection the licensee did not ensure building and grounds were in good repairs. Broken exterior fence, broken canopy blocking the emergency gate, electric plate plugs are missing in room 2 and 4, light bulb is missing in hall way light fixture. This pose a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 30, 2023

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Feb 23, 2023

87412(a) Personnel Records: The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This requirement was not met as evidence by: Based on observation and file review, the Licensee did not ensure all staff files were completed. The facility did not have a staff file for Staff 1. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 30, 2023

The state marks this report as 7 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Food services are inadequate. Facility is not properly maintained. Facility is unsanitary.

Licensing Program Analyst (LPA) Anthony Tuck arrived at the facility unannounced and was met by Staff Prince Ehimaniegho on 01/03/2021. LPA explained the purpose of today's visit to conclude the complaint investigation and review findings for the allegation listed above. LPA conducted interviews with R1, R2, R3, R4, R5, and R6 and S1 on 12/10/2021 at the facility during the initial investigation. LPA learned that 4 out of 6 residents were unhappy with the quality of certain meals being served at the facility. LPA observed R6 during an interview to have trouble remembering what meals he had. LPA attempted to interview R5. R5 stated that she did not want to be interviewed and had no complaints. LPA observed several light fixtures either missing bulbs or had bulbs that were burnt out during the investigation. LPA observed the shower in the master bedroom that is shared by R3 and R2. LPA discovered lime and calcium build up on the shower floor. LPA obtained photographs of discovered lighting issues and unsanitary shower floor. LPA observed and obtained photographs of food kept in refrigerator, freezer and pantry, LPA obtained copy of weekly menu. LPA discovered that the facility has several packs of frozen hot-dogs in the freezer and fridge after learning that hot-dogs are not on the weekly food menu. Continued on LIC 9099C... Substantiated Based upon observation of food kept in the facility and interviews with 4 out of 6 residents, the facility is not following the weekly menu. The preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. The following deficiency was observed (see LIC 9099-D) and cited from the California Code of regulations Title 22. Failure to correct the deficiencies may result in civil penalties. Appeal rights were provided. Exit interview was conducted with Justice Ehimaniegho . LPA generated the report for the staff to sign. A copy of the report LIC 9099, LIC 9099C, LIC 9099-D, and appeal rights were provided upon exit.the state’s words, verbatim · CDSS document, Jan 3, 2022 · control 27-AS-20211206143822

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(a) · Plan of correction due date: Jan 10, 2022

87555(a) General Food Service Requirements (a)The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council… This was not met as evidenced by: Based upon interviews with residents, staff, documents, and observation, the licensee did not ensure that the weekly food menu was being followed by staff food items that were not on the weekly menu were found in the fridge and freezer and being served to residents. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 3, 2022

Plan of correction: Licensee agrees to remove all food items that are not part of the weekly menu and update the weekly food menu to include new meal selections to be served weekly and special meals to be served on occasion. Licensee will send a copy of updated weekly food menu to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(d) · Plan of correction due date: Jan 10, 2022

(d)There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility. This was not met as evidenced by: Based on interviews with residents and observations, the Licensee failed to ensure that the facility had sufficient lamps or lighting in each room. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 3, 2022

Plan of correction: Licensee has already replaced or repaired all light fixtures in the facility. Licensee agrees to create a schedule for maintenance repairs to be checked at the facility on a weekly basis. Licensee will send a copy of the maintenance schedule to CCLD by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a)(1) · Plan of correction due date: Jan 10, 2022

87303(a)(1) Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times… (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This was not met as evidenced by: Based on interviews with residents and observations, the Licensee failed to ensure that floor surfaces in bathrooms were maintained to be kept clean and safe and sanitary. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 3, 2022

Plan of correction: Licensee agrees to ensure that staff are maintaining a clean, safe and sanitary facility and ensure that resident bathroom floors and surface's are kept clean and free from calcium and lime build up. Licensee will create an additional duty list for staff to complete while conducting daily activities at the facility. Licensee will submit a copy of the new staff daily activity schedule to CCLD by POC due date.

Type of visit: Annual/Random

Licensing Program Analyst (LPA) Anthony Tuck Island arrived to conduct an unannounced annual/random inspection on 01/03/2022. LPA met with Justice Ehimamiegho and explained the purpose of the visit. Justice Ehimamiegho is the Administrator and holds certificate #6038919740 that expires on 06/11/2022 This facility is a single story building licensed to serve six (6) non-ambulatory residents and a waiver to service 2 hospice residents. LPA toured the physical plant including but not limited to two resident bedrooms, two resident bathrooms, garage and backyard area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at (106) degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers and smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguisher last serviced 01/03/2022. Thermostat observed at (72) degrees Fahrenheit. LPA observed centrally stored medications, toxins and sharp knives kept locked and inaccessible to clients. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed staff associations to the facility. First aid kit was checked and is complete. LPA received an updated copy of the certificate of liability insurance during visit. All other documents are current and updated on file. No Deficiencies were found during today's inspection. Exit interview held with Justice Ehimamiegho and a copy of report given at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jan 3, 2022

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Facility did not provide resident with a comfortable mattress

Licensing Program Analyst (LPA) Anthony Tuck arrived at the facility unannounced and was met by Staff Stephanie Siewe on 12/29/2022. LPA explained the purpose of today's visit to conclude the complaint investigation and review findings for the allegation listed above. Staff contacted Licensee Justice Ehimaniegho via telephone to be present during visit. Licensee arrived shortly after called and met with LPA. LPA conducted interviews with R4 and R2 and S1 on 12/10/2021 during the initial investigation. LPA learned that the facility replaced the bed mattress for both R2 and R4 with spare mattresses that were never used. LPA inspected the condition of the bed mattress for R2 and R4. LPA did not find any issues with the condition of either mattress. LPA observed both mattresses to be basic standard mattresses in new condition. This agency has investigated the allegation listed above. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint. Exit interview was conducted with Justice Ehimaniegho, a copy of the report was left with the facility upon exit. No deficiencies were cited during this investigation. Unfoundedthe state’s words, verbatim · CDSS document, Dec 29, 2021 · control 27-AS-20211206153726

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Anthony Tuck Island arrived to conduct an unannounced annual/random inspection on 07/20/2021. LPA met with staff Prince Ehimamiegho and explained the purpose of the visit. Justice Ehimamiegho is the Administrator and holds certificate #6038919740 that expires on 06/11/2022 This facility is a single story building licensed to serve six (6) non-ambulatory residents and a waiver to service 2 hospice residents. LPA toured the physical plant including but not limited to two resident bedrooms, two resident bathrooms, garage and backyard area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 106 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers and smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguisher last serviced 11/30/2020. Thermostat observed at 79 degrees Fahrenheit. LPA observed centrally stored medications, toxins and sharp knives kept locked and inaccessible to clients. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed staff associations to the facility. First aid kit was checked and is complete. The following forms need updating and were collected during visit on 07/20/2021: LIC 308, LIC 500, LIC 610, copy of Administrator Certificate, copy of liability Insurance. Per California Code of Regulations, Title 22 Division 6, Chapter 8, Exit interview held with Prince Ehimamiegho and a copy of report given at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jul 20, 2021

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.