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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880690
Report Date: 05/05/2023
Date Signed: 05/05/2023 05:27:34 PM

Document Has Been Signed on 05/05/2023 05:27 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
RIVERSIDE ASC, 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:
05/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:28 PM
MET WITH:Dulce Carrillo, Lead caregiverTIME COMPLETED:
05:40 PM
NARRATIVE
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On 05/05/2023, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced at the facility to conduct an annual inspection. LPA Nwogene was greeted and granted entry by caregiver, Alyssa Traylor. LPA also met with lead caregiver, Dulce Carrillo who was informed of the purpose of visit. At the time of visit there was 2 staff and 3 residents present. LPA toured the facility inside and out with Dulce Carrillo and Alyssa Traylor.

Tour included:

Kitchen; LPA toured the kitchen and observed kitchen to be clean. Food is stored in a safe and healthful manner. Utensils and dishware are sufficient for the approved capacity. The refrigerator and stove are in working order. Sharps are stored in a locked kitchen drawer, available only to authorized individuals. Trash cans has tight-fitting lids. All need appliances were present and shown to be in working condition and clean. The fridge was measured at 40 degrees Fahrenheit and Freezer was measures at 0 degrees Fahrenheit.

Dining and Livingroom; LPA toured the dinning and Livingroom area. LPA observed area to be clean and furnitures in good condition. Temperature was 71 degrees Fahrenheit.

Hallway; LPA toured the hallway and observed hallway to be clean with no pathway obstruction. LPA inspected the fire extinguisher and found it to be in compliance and record to be up to date. Carbon monoxide & smoke detector were tested and functioning properly. LPA observed additional linens and hygiene items.

Medication; LPA observed medications were labeled and stored in separate bins inside of a locked medication cabinet and are distributed according to physician orders. The first aid kit was complete.

Bathroom; LPA toured two #2 out of #2 residents bathrooms and observed bathrooms to be clean and equipped with grab bar. There is also a good number of personal toiletries available for the residents in care. The hot water measured at 137 degrees Fahrenheit which is above regulatory limit. A citation will be issued.

Continue on LIC809-C

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2023
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 6
Document Has Been Signed on 05/05/2023 05:27 PM - It Cannot Be Edited


Created By: Chinwe Nwogene On 05/05/2023 at 03:59 PM
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: 05/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(c)
Personnel Records:
(c) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. removal of records shall be subject to the following requirements:
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review and interview, the licensee did not comply with the section cited above by not not having Administartor's file available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2023
Plan of Correction
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Dulce stated moving forward the administrator file will be available for licensing agency review. Dulce stated a written understanding of the regulation cited above will be provided to LPA by the POC due dat 5/15/2023.
Type B
Section Cited
CCR
800(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not having health screening documentation for two #2 staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2023
Plan of Correction
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Dulce stated the health screening documentation for the two #2 staff will be provided to LPA by the POC due date 5/15/2023.
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:Joel Esquivel
LICENSING EVALUATOR NAME:Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2023


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 05/05/2023 05:27 PM - It Cannot Be Edited


Created By: Chinwe Nwogene On 05/05/2023 at 04:06 PM
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: 05/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80044(a)
Inspection Authority of the Licensing Agency

(a) The licensing agency shall have the inspection authority

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not having the two bedrooms on second floor accessible for LPA to inspect which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2023
Plan of Correction
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Dulce stated moving forward the two bedrooms will be made accesible to licensing agency for inspection. Dulce stated a written understanding of the regulation cited above will be provided to LPA by the POC due dat 5/15/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Joel Esquivel
LICENSING EVALUATOR NAME:Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2023


LIC809 (FAS) - (06/04)
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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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: EHIEMERE RESIDENTIAL CARE HOMES
FACILITY NUMBER: 331880690
VISIT DATE: 05/05/2023
NARRATIVE
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Continued from LIC809.

Bedroom; LPA toured four #4 out of #4 residents bedroom and observed bedrooms to be clean and furnished according to regulation, which includes proper furniture, dressers, chairs and lighting. Night lights were maintained throughout the facility.

Garage; LPA tour the garage and observed garage to be clean and not cluttered.

Laundry; LPA toured the laundry room and observed room to be clean. Washing machine and dryer are all in good repair and sufficient for approved capacity. Cleaning supplies are stored away in a locked closet in the hallway, inaccessible to clients,

Backyard; LPA toured the backyard and observed backyard to be clean and furnitures in good condition. The backyard was free from obstruction and the side gates remain unlocked. No bodies of water were observed.

Food Services: There are seven days non-perishable and two days of perishable food supply present, and all food was properly stored and available to residents.

Records: All required postings, including COVID’s postings, were posted near the entryway and throughout the facility. All staff present have a criminal record clearance in file and are confirmed as being associated with the facility. Three #3 staff and #3 residents' records were reviewed. LPA observed two #2 staff has no health screening and one #1 resident has no Medical Assessment documentation. LPA requested for Administrator, Chyke Ehimere’s file but file was not available for LPA to review. LPA inquired about the infection control plan and was told facility has no infection plan. Four #4 citations will be issued.

Interview: Three #3 residents and two #2 staff present were interviewed.

During LPA’s tour, LPA requested to view two #2 bedrooms on the second floor but was told the rooms are locked and the key is not available. LPA informed Dulce Carrillo that a citation will be issued, and a civil penalty will be accessed.

Therefore, based on the observations made during today’s visit, six #6 citations will be cited, and one (1) civil penalty will be assessed in the amount of $500, Per Title 22, Division 6 of the California Code of Regulations. See LIC 809D. An exit interview was conducted, and this reported was provided along with appeal rights to Dulce Carrillo.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 05/05/2023 05:27 PM - It Cannot Be Edited


Created By: Chinwe Nwogene On 05/05/2023 at 04:40 PM
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: 05/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.2(b)(1)(c)
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069.

This requirement is not met as evidenced by:
Deficient Practice Statement
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This requirement is not met as evidenced by:Based on observation and record review, the licensee did not comply with the section cited above by not having a written medical assessment form for resident #2 and #3 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2023
Plan of Correction
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Dulce stated the medical assessment documentation for the two #2 staff will be provided to LPA by the POC due date 5/15/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Joel Esquivel
LICENSING EVALUATOR NAME:Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/05/2023 05:27 PM - It Cannot Be Edited


Created By: Chinwe Nwogene On 05/05/2023 at 05:09 PM
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: 05/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(5)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not having Infection Control Plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2023
Plan of Correction
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Dulce stated Infection Control Plan will be provided to LPA by the plan of correction due date 5/15/2023.
Type B
Section Cited
CCR
80088(e)(1)
Furniture, Fixtures, Equipment, and Supplies ;
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water.
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above by having Hot water temperature at 137 degrees Fahrenheit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2023
Plan of Correction
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Dulce stated the Hot water temperature will be adjusted and proof provided to LPA by the POC due date 5/15/2023.
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:Joel Esquivel
LICENSING EVALUATOR NAME:Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2023


LIC809 (FAS) - (06/04)
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