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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700903
Report Date: 10/23/2020
Date Signed: 10/23/2020 04:02:29 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:EHIMAS RESIDENTIAL CAREFACILITY NUMBER:
342700903
ADMINISTRATOR:EHIMAMIEGHO, JUSTICE OSASEFACILITY TYPE:
740
ADDRESS:407 MAPLE STREETTELEPHONE:
(408) 791-9763
CITY:GALTSTATE: CAZIP CODE:
95632
CAPACITY:18CENSUS: 14DATE:
10/23/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Justice EhimamieghoTIME COMPLETED:
12:30 PM
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A unannounced prelicensing visit made via Zoom to the facility on 10/23/20 and was met by the Applicant, Justice Ehimamiegho. LPA Jason Lund explained the reason for the visit.

It was learned that this facility will be licensed to serve up to (18) residents at any given time. The facility has a fire clearance for 6 non-ambulatory and 12 ambulatory residents There are 14 residents in care during today's prelicensing visit.

Tour of the facility was conducted via zoom. Tour of this facility was conducted. Common rooms were toured. Dining room was toured. This LPA observed that seating and furnishings were present and in compliance at this time.

Kitchen area was toured and observed at this time, there is 2 day perishable and 7 day non-perishable food in the facility. Hot water temperatures were taken and measured at 111 degrees and within the allowed range of 105-120 degrees.
Facility Medication Room is shared with the laundry room, LPA observed medication cabinets and the first aid kit.

Fire extinguishers were located throughout this facility and observed to have been recently inspected and the next review date in 11/14/20 and in compliance at this time.
Exterior grounds of this facility was toured. Facility perimeter fence, gates, and latches were reviewed.


This facility has been found to be in compliance at this time.
Component 111 requirements were also done during the visit and completed.
Report will be emailed for signature and emailed back to LPA Lund
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2020
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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