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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880690
Report Date: 09/13/2021
Date Signed: 09/13/2021 10:59:24 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/07/2021 and conducted by Evaluator David Cuevas
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210907164147
FACILITY NAME:EHIEMERE RESIDENTIAL CARE HOMESFACILITY NUMBER:
331880690
ADMINISTRATOR:EHIMERE, CHYKEFACILITY TYPE:
735
ADDRESS:1051 HARRIER STTELEPHONE:
(951) 992-9065
CITY:PERRISSTATE: CAZIP CODE:
92571
CAPACITY:6CENSUS: 3DATE:
09/13/2021
UNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Administrator, Chyke EhimereTIME COMPLETED:
11:10 AM
ALLEGATION(S):
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Staff are mismanaging resident's medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Cuevas arrived at the facility unannounced for the purpose of initiating an investigation for a complaint with the above allegation. LPA Cuevas was granted entrance and met with Licensee/Administrator, Chyke Ehimere.

Regarding this investigation LPA Cuevas conducted interviews, review resident files, and collected pertinent documents.

During today’s complaint visit, LPA reviewed MAR log for resident # 1 R1 along with staff # 1 S1 and identified medication input errors in MAR. Per S1 the input errors were identified, and an action plan will be developed to correct future errors. Additionally, review of medication identified a medication that is no longer prescribed to R1. S1 disposed of discontinued medication while LPA was on visit.

Based on the evidence reviewed today and statements provided the allegation of, staff are mismanaging resident's medication is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted with Licensee/Administrator, Chyke Ehimere. and a copy of this report, LIC9099D, and appeal rights was provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: David Cuevas
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 18-AS-20210907164147
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: EHIEMERE RESIDENTIAL CARE HOMES
FACILITY NUMBER: 331880690
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/20/2021
Section Cited
CCR
80075(B)
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If the client's physician has stated in writing that the client is unable to determine his/her own... facility staff designated by the licensee shall be permitted to assist the client...(B) Once ordered by the physician the medication is given according to the physician's directions.This was not met evidence by.
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Licensee will conduct staff training to address proper dose to be given and how to log proper dose in MAR log by POC due date,
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During todays visit S1 and LPA reviewed MAR and medication and identified errors in medication and a discontinued mediaction that should be disgarded. Staff dispose of discontinued medication while LPA on visit.
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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.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: David Cuevas
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2