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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700903
Report Date: 08/31/2022
Date Signed: 08/31/2022 05:00:24 PM


Document Has Been Signed on 08/31/2022 05:00 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
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:
(916) 912-8042
CITY:GALTSTATE: CAZIP CODE:
95632
CAPACITY:18CENSUS: 15DATE:
08/31/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Justice EmihamieghoTIME COMPLETED:
12:18 PM
NARRATIVE
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On 8-31-22 at 9:58am, Licensing Program Analysts (LPAs) Michael Bilger and Renee Campbell arrived unannounced to conduct a case management visit based on various incidents occurring between 5-20-22 and 8-19-22. LPAs met with Administrator Justice Ehimamiegho and explained the purpose of the visit. LPAs also interviewed Administrator, staff1 (S1), and reviewed facility file documentation. LPAs also reviewed police report call log. Based on record review it was determined that a total of 38 9-1-1 calls where made between the dates of 5-20-22 and 8-19-22. Upon further review, it was determined that facility did not ensure incident reports sent to Licensing department for multiple incidents occurring between this time period.

In addition, during this case management, it was determined through record review that an incident occurred which resulted in a 9-1-1 call by a resident1 (R1) on 7-9-22, alerting police of an alleged altercation between R1 and R2. This same 9-1-1 call also alerted police of an alleged altercation between R2 and R3. LPAs also interviewed R2 and R3. Based on interviews and staffing schedule reviewed, it was determined that two staff members were on duty at time of alleged incident in which R1 called 9-1-1.

Based on today’s case management, citations are issued under Title 22, division 6, chapter 8, and health and safety code. An exit interview was conducted with Justice Ehimamiegho and a copy of this report was left with Justice. Appeal rights provided.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2022
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 08/31/2022 05:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 342700903

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/01/2022
Section Cited

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Reporting Requirements. (a) Each licensee shall furnish to the licensing agency...(1) A written report shall be submitted to the licensing agency...within seven days of the occurrence...(D)Any incident which threatens the welfare, safety or health of any resident...The requirement was not met as evidenced by:
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Based on record review and interview, licensee did not ensure reports sent to licensing agency for multiple incidents occurring between 5-20-22 and 8-19-22. This poses an immediate health and safety 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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2