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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880690
Report Date: 05/10/2024
Date Signed: 05/10/2024 02:01:03 PM

Document Has Been Signed on 05/10/2024 02:01 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/
DIRECTOR:		EHIMERE, CHYKEFACILITY TYPE:
735
ADDRESS:1051 HARRIER STTELEPHONE:
(951) 992-9065
CITY:PERRISSTATE: CAZIP CODE:
92571
CAPACITY: 6CENSUS: 2DATE:
05/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Licensee, Chyke EhiemreTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted a required annual visit. LPA met with Licensee, Chyke Ehiemere, who was informed of the purpose of the visit. At time of visit there was (1) clients and (2) staff present.

The facility is a two story home, with a total of (6) bedrooms and (3) bathrooms (2) bedrooms are used as staff rooms. The home has an attached garage, and no fire arms and no pool. The facility is an adult residential facility. LPA observed the following:

Infection Control: LPA observed hand hygiene supplies and cleaning supplies to do regular cleaning of the facility. The facility has a infection control plan on file.

Physical Plant: Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility's outdoor area was observed to be free of hazards. The carbon monoxide detector was tested and operational during the visit. Hot water temperature was recorded in client shower at 105F.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required food items.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2024
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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Document Has Been Signed on 05/10/2024 02:01 PM - It Cannot Be Edited


Created By: Janira Arreola On 05/10/2024 at 01:16 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: 05/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(l)(1)
80075 Health Related Service (l) Prescription medications...which are not to be retained shall be destroyed by the facility administrator, or a designated substitute, and one other adult who is not a client. (1) Both shall sign a record, to be retained for at least one year….


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above with client medications that were discontinued and being kept at the facility. Interview revealed staff do not document medication destruction which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
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LPA observed the discontinued medications are kept locked. The lciensee agreed to destroy the medications and sent the destruction record to LPA by the POC due date.
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:Tricia Danielson
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024


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: 05/10/2024
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Record Review and Resident/Staff Files: LPA reviewed staff files, administrator file, training along with CPR/First Aid. All (7) files had required paper work. (2) Client files were reviewed and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked and all client medications were accounted for in MARS list. LPA found the facility had a store of discontinued medications that had not been destroyed. According to staff interview destroyed medications are not documented. Therefore, a deficiency was issued and a plan of correction was created with staff.

Disaster preparedness: Emergency and Disaster Plan was unable to be located at the time of the visit. The licensee agreed to send by next week May 17, 2024. LPA reviewed documentation showing last fire drill April 4, 2024.

An exit interview was conducted where a copy of this report, 809-D page, and appeals rights were reviewed and provided to Licensee, Chyke Ehiemre.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
LIC809 (FAS) - (06/04)
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