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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700903
Report Date: 03/06/2023
Date Signed: 03/06/2023 04:17:22 PM


Document Has Been Signed on 03/06/2023 04:17 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: 18DATE:
03/06/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Justice EhimameighoTIME COMPLETED:
04:30 PM
NARRATIVE
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On 3/6/23 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to open a complaint investigation-See complaint number 27-20230303123659. LPA Jensen met with Licensee Justice Ehimamiegho and explained the purpose of today's visit.

LPA Jensen interviewed Licensee Justice who confirmed that the facility does not currently have a functioning signal system that operates from each resident room. This facility is licensed for 18 residents and therefore requires a functioning signal system .

Deficiencies are being cited from the California Code of Regulations (CCR), Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

In addition, the facility was cited on 2/23/23 for having an inoperable washing machine. The citation gave a Plan of Correction with a due date 3/2/23 to submit a repair receipt or replacement receipt. To date no invoices have been submitted. LPA Jensen interviewed the Licensee who stated that the machine is under warranty and he is waiting on the vendor to receive parts or if they are unable to obtain the needed part they will replace the unit.

Civil penalties are being assessed for failure to correct deficiencies. Further failure to correct deficiencies may result in administrative action.

An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2023
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 03/06/2023 04:17 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: 03/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/20/2023
Section Cited

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All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall:

(A) Operate from each resident's living unit.

(B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff.

(C) Identify the specific resident living unit.
This requirement was not met as evidenced by:
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The Licensee agrees to install a signal system by 3/20/23 and will email a receipt to maja.jensen@dss.ca.gov
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LPA's observation of the facility call system being inoperable and interview with Licensee who confirmed that the facility does not currently have a working signal system. This poses a potential risk to teh health, safety and personal rights of 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: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2023
LIC809 (FAS) - (06/04)
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