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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880690
Report Date: 10/30/2024
Date Signed: 10/30/2024 02:50:48 PM

Document Has Been Signed on 10/30/2024 02:50 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:
10/30/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Daisy Miranda - Staff TIME VISIT/
INSPECTION COMPLETED:
03:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced case management visit to address the following the deficiencies observed on 10/30/2024 visit.

LPA observed one (1) camera in the dining room area with visual and audio capabilities pointing towards the dining room, living room, and kitchen area. Interviews with Administrator Chyke Ehimere reported the camera has both visual and audio. Through file review it was noted that plan of operation and admissions agreement for Client One (C1) and Client Two (C2) had not been updated to reflect the use of cameras at the facility with audio capabilities. A deficiency will be issued under Title 22 Regulation 80072(a)(1) along with a plan of correction.


An exit interview was conducted, and a copy of this report, LIC 809-D, appeal rights, LIC 811 was provided to Daisy Miranda.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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 10/30/2024 02:50 PM - It Cannot Be Edited


Created By: Sara Martinez On 10/30/2024 at 02:15 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: 10/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/22/2024
Section Cited
CCR
80072(a)(1)

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80072 Personal Rights
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:
(1) To be accorded dignity in his/her personal relationships with staff and other persons.
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Licensee will remove the camera from the facility and send proof of camera being removed to LPA by the plan of correction date. If camera is going to be kept, Licensee will amend plan of operation, admission agreement as outlined in Guidance for Use of Video Surveillance 2-5800 and 2-5801.
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This requirement was not met as evidenced by: based on interviews and record review, facility has cameras with audio capabilities without notification or approval of the department. This poses a potential health safety or personal rights risk to residents in care.
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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:Sara Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2024


LIC809 (FAS) - (06/04)
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