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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881194
Report Date: 01/15/2025
Date Signed: 01/15/2025 06:08:53 PM

Document Has Been Signed on 01/15/2025 06:08 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:
331881194
ADMINISTRATOR/
DIRECTOR:		EHIEMERE, CHYKEFACILITY TYPE:
735
ADDRESS:14311 QUINCY STREETTELEPHONE:
(951) 992-9065
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 4CENSUS: 1DATE:
01/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Estefany Rodriguez Hinojosa, Care StaffTIME VISIT/
INSPECTION COMPLETED:
06:15 PM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Martinez, made an unannounced visit to the facility for the purpose of conducting a required annual inspection. On today’s visit the LPA met with staff, Estefany Rodriguez Hinojosa; she was notified of the purpose for the visit. Administrator, Chyke Ehiemere, who is currently out of the country, was contacted via telephone by the LPA and the staff member; however, he could not be reached for notification.

PHYSICAL PLANT AND ENVIRONMENTAL SAFETY: The Licensee appears to be operating the facility within the conditions and limitations specified on the license. There is currently 1 client in care. Outdoor and indoor passageways are kept free of obstruction. No pool or other body of water was observed on the property. Per staff, there are no weapons kept in the home. Disinfectants, cleaning solutions, and poisons were inaccessible to clients in care. A comfortable temperature was being maintained in the home. There was sufficient lighting in all rooms to ensure the comfort and safety of clients. Toilets, hand washing and bathing facilities were kept safe, sanitary, and in operating condition. The smoke and carbon monoxide alarms were tested and found to be operable. The interior areas of the home were observed to be very clean and safe.

Operational Requirements: The Licensee has secured and appears to be maintaining the approved fire clearance.

STAFFING: Review of the facility's staff schedule revealed one staff member to be scheduled for all three shifts from 01/07/25 through 01/16/25. Per staff, only 1 staff member is scheduled for the whole day. Staff are trained in emergency procedures and medication administration. The LPA observed that Staff #1 was unable to continue the operation or the carrying out of the administrator's responsibilities during their absence. Staff #1 was unable to assist the LPA with obtaining facility records and had to contact Staff #2 (staff who works at another facility) to facilitate the visit. A citation will be issued.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 331881194
VISIT DATE: 01/15/2025
NARRATIVE
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PERSONNEL RECORDS - TRAINING: Administrator has an active Administrator's Certificate. All staff members have had health screenings completed with TB test results listed. Staff present had the required criminal record clearance; however, the staff member (Staff #1) was not listed on the facility roster. No proof of a transfer request was observed on file and could not be found by staff. A citation will be issued. Staff files had required training; including, but not limited to, medication training and First Aid/CPR training. LPA observed that one (1) out of one (1) staff members was insufficient to meet client's needs. LPA observed there to be 1 staff (S1) available during the start of the inspection. LPA observed 2 clients in care during visit (1 client who was visiting from another facility). S1 reported they are on shift 24/7 & do not take breaks. S1 was unable to provide assistance to the LPA & so S2 (staff of another facility) came to assist the LPA. In addition, information was obtained revealing Client #1 (C1) has been taken outside of the facility to the personal home of staff to maintain supervision, due to limited staffing available. It was also reported that when Administrator, Chyke Eheiemere, is on shift, he takes C1 with him whenever he needs to leave the facility. Client records, such as the appraisal/needs and services plan or the Individual Program Plan (IPP) were not available for review to ensure what type of supervision is required for C1. A citation will be issued.

CLIENTS RIGHTS - INFORMATION: An internet accessible device is available for clients use.

Food Service: The LPA inspected the facility's kitchen areas and food supply. LPA observed a cut melon and a bowl of cake that were not covered in the refrigerator. A citation will be issued. Soaps, detergents, cleaning compounds and similar substances were stored in areas separate from food supplies. All kitchen areas were kept clean and free of litter, rodents, vermin, and insects.

CLIENT RECORDS - INCIDENT REPORTS: C1 did not have a written admission agreement on file. A citation will be issued. C1 did not have a written Needs and Services Plan on file. A citation will be issued. A medical assessment (including TB test results), and centrally stored medication and destruction records were observed on file.

Health Related Services: The licensee is ensuring client's first aid and other needed medical or dental needs are being met for C1. Clients are being assisted with administration of prescribed medications. Client medications were observed to be appropriately labeled. Medications were observed to be centrally stored in a safe and locked area.

EXIT: This report was reviewed with Staff Rodriguez Hinojosa and a copy was provided, along with supportive documentation.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 01/15/2025 06:08 PM - It Cannot Be Edited


Created By: Stephanie Martinez On 01/15/2025 at 04:27 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: 331881194

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80064(b)
Administrator - Qualifications and Duties: (b) Each licensee shall make provision for continuing operation and carrying out of the administrator's responsibilities during any absence of the administrator.

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 in one (1) out of one (1) staff members who were unable to continue the operation or the carrying out of the administrator's responsibilities during their absence. Facility staff (Staff #1)was unable to assist the LPA with obtaining facility records and had to contact Staff #2 (staff who works at another home) to facilitate the visit. This poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 01/22/2025
Plan of Correction
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Care Staff Rodriguez Hinojosa reported she will train S1 on proper operation of the facility and will submit proof of the training to the Department by the POC due date.
Type B
Section Cited
CCR
80019(e)(3)
Criminal Record Clearance All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 80019(f) or...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 1 staff members who were not listed on the facility's personnel roster. No transfer of a criminal record clearance was observed on file. According to Staff #2, there was no knowledge of whether the administrator attempted to request a transfer request for S1. This poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 01/17/2025
Plan of Correction
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Care Staff Rodriguez Hinojosa reported she would have a transfer request completed and submitted to the Department by the POC due date.
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:Rikesha Stamps
LICENSING EVALUATOR NAME:Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/15/2025 06:08 PM - It Cannot Be Edited


Created By: Stephanie Martinez On 01/15/2025 at 05:04 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: 331881194

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80065(a)
Personnel Requirements
(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.

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 in one (1) out of one (1) staff members was insufficient to meet client's needs...This poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 02/17/2025
Plan of Correction
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Care Staff Rodriguez Hinojosa reported she would work in unison with Administrator Chyke on obtaining additional staffing and will provide a written update on the status of their efforts to the Department by the POC due date.
Type B
Section Cited
CCR
80076(a)(18)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (18) All food shall be protected against contamination. Contaminated food shall be discarded immediately.

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 in 2 out of 2 food items that were not protected against contamination. LPA observed a cut melon and a bowl of cake that were not covered in the refrigerator. This poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 01/15/2025
Plan of Correction
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Care Staff Rodriguez Hinojosa removed the food items from the refrigerator during the LPA's visit.
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:Rikesha Stamps
LICENSING EVALUATOR NAME:Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 01/15/2025 06:08 PM - It Cannot Be Edited


Created By: Stephanie Martinez On 01/15/2025 at 05:04 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: 331881194

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 1 clients who did not have a written admission agreement on file. This poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 01/17/2025
Plan of Correction
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Care Staff Rodriguez Hinojosa stated she would reach out to C1's placement agency and Administrator Ehiemere, obtain a copy of the admission agreement, and submit a copy to the Department by the POC due date.
Type B
Section Cited
CCR
85068.3(a)
Modifications to Needs and Services Plan
(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 1 clients who did not have a written Needs and Services Plan or Individual Program Plan (IPP) on file. This poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 01/17/2025
Plan of Correction
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Care Staff Rodriguez Hinojosa stated she would reach out to C1's placement agency and Administrator Ehiemere, obtain a copy of the plan, and submit a copy to the Department by the POC due date.
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:Rikesha Stamps
LICENSING EVALUATOR NAME:Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2025


LIC809 (FAS) - (06/04)
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