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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701518
Report Date: 04/21/2025
Date Signed: 04/28/2025 12:41:17 PM

Document Has Been Signed on 04/28/2025 12:41 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:EBONY & CECILIA RESIDENTIAL CARE FACILITYFACILITY NUMBER:
392701518
ADMINISTRATOR/
DIRECTOR:		ALIRIAGWU, EBONYFACILITY TYPE:
740
ADDRESS:1660 CHATEAU LNTELEPHONE:
(916) 346-9838
CITY:MANTECASTATE: CAZIP CODE:
95337
CAPACITY: 6CENSUS: 0DATE:
04/21/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Ebony AliriagwuTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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On 4/21/25 at 9:30 am, Licensing Program Analyst (LPA) Noel Wolf Petersen and Licensing Program Manager(LPM) Liza King arrived announced to perform a pre licensing inspection, and met with administrator/licensee Ebony Aliriagwu and explained the purpose of the visit.

LPA requested and reviewed several documents and needs more submitted in a more complete fashion before we continue, including but not limited to all required posters, the plan of operation, the admission agreement, the LIC 308, the evacuation plan, the infection control plan. They should be printed out and available for licensing to audit.

LPA inspected the Physical Plant, including but not limited to the common areas, resident bedrooms, resident bathrooms, and the outdoor area, and had concerns of incomplete preparedness including but not limited to: the storage of the fire extinguishers being locked and inaccessible, the posters not being up, the rubber mats not being in the showers, the bathroom trashcans with lids missing, the nightlights in the halls/bathrooms missing. Grab bars for the non ambulatory bathroom toilet and shower, the walkways to the emergency exit were obstructed in the master bedroom and the cameras had microphones (in the kitchen area and along the side of the house and backyard).

LPA inspected emergency preparedness procedures, required postings, and kits, including the first aid kit and found the required items. The fire extinguisher was not dated, but purchased 11/4/24 and the water temperature of the residents bathroom was measured at 118degrees between the required 105-120* F.

Cont on pg C



NAME OF LICENSING PROGRAM MANAGER: Krystall Moore
NAME OF LICENSING PROGRAM ANALYST: Liza King
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: EBONY & CECILIA RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 392701518
VISIT DATE: 04/21/2025
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The facility is not in a condition to accept clients at this time, and LPA did not perform a staff interview or give the Comp III presentation. LPM assisted Ebony with the Technical Support Program(TSP) referral, and the LPA will return when the Licensee is more prepared. An exit interview was conducted and a copy of the report was read and delivered to the administrator via papercopy since the LPA and LPM experienced technical issues.

Final print was conducted on 04/23/25 and a copy of this report was provided via email. A folllow up visit is scheduled at this time for May 9, 2025 at 930am.
NAME OF LICENSING PROGRAM MANAGER: Krystall Moore
NAME OF LICENSING PROGRAM ANALYST: Liza King
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2025
LIC809 (FAS) - (06/04)
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