<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880690
Report Date: 05/26/2022
Date Signed: 06/22/2022 10:31:12 AM

Document Has Been Signed on 06/22/2022 10:31 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
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: 4DATE:
05/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Pamela Wilkerson, House ManagerTIME COMPLETED:
04:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control. LPA arrived at 2:05 PM, LPA was met by House Manager Pamela Wilkerson and explained the purpose of the visit. Present in the facility during time of visit were two (2) staff as well as four (4) residents. There are currently no cases of COVID-19 within the facility.

During today's visit, LPA toured the facility and made observations pertaining to the facility's infection control measures. LPA observed insufficient signage throughout the facility, sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and proper use of face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, PPE supplies need to be maintained at the facility, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE and overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and residents for COVID-19, when and how to isolate/quarantine residents, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also needs to maintain a plan to monitor resident(s) regularly for any changes in condition and to subsequently notify the resident(s) physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

Based on the observations made during today’s visit, four (4) deficiencies were cited per Title 22, Division 6, of the California Code or Regulations. An exit interview to review this report was conducted and a copy of this report was provided.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 06/22/2022 10:31 AM - It Cannot Be Edited


Created By: Yolanda Delgado On 06/22/2022 at 08:44 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 05/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087.2(b)
Outdoor Activity Space:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado's observation, there was no patio furniture-table, shade and chairs for residents to use, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2022
Plan of Correction
1
2
3
4
The licensee will obtain and provide outdoor patio furnishings and will submit proof of correction to CCLD by 5pm on POC.
Type B
Section Cited
CCR
85076(d)(1)
Food Service:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado's observation of the refrigerator in the kitchen, there was insufficient nonperishable foods for a minimum of 1 week and insufficient fresh perishable foods for a minimum of two days during the inspection. The licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2022
Plan of Correction
1
2
3
4
The licensee will purchase and obtain nonperishable foods and fresh perishable foods for the residents in care and maintain foods at the facility at all times. The licensee will submit proof of correction to CCLD by 5pm on POC.
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:Jazmond D Harris
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/22/2022 10:31 AM - It Cannot Be Edited


Created By: Yolanda Delgado On 06/22/2022 at 09:15 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 05/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087(b)
Buildings and Grounds: (b) Stairways, inclines, ramps, open porches, and areas of potential hazard to clients whose balance or eyesight poor shall not be used by clients unless areas are well lighted and equipped with sturdy hand railings.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado's observation, the laundry room has a light that is flickering and dim, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2022
Plan of Correction
1
2
3
4
The licensee will repair light inside the laundry room and submit proof of correction to CCLD by 5pm on POC.
Type B
Section Cited
CCR
80072(a((2)
Personal Rights: (a) Except for children's residential facilities, each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful, and comfortable accomodations, furnishings and equipment to meet his/her needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado's observation, interview and record review, the licensee did not ensure COVID-19 Infection Control measures: COVID-19 screening protocols and practives for all staff, residents and visitors. Licensee failed to comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care as required by the CA Dept. of Public Health Guidance.
POC Due Date: 05/30/2022
Plan of Correction
1
2
3
4
The licensee will obtain additioal PPE supplies, comply screening protocols and practice. Proof of correction will be submitted to CCLD by 5pm on POC.
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:Jazmond D Harris
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2022


LIC809 (FAS) - (06/04)
Page: 3 of 3