342700903-2-23-2023-27-AS-KHOS-CPPS8W-20230307123946

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700903
Report Date: 02/23/2023
Date Signed: 02/23/2023 11:29:03 AM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/09/2022 and conducted by Evaluator Renee Campbell

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20221209083147

FACILITY NAME:	EHIMAS RESIDENTIAL CARE		FACILITY NUMBER:	342700903
ADMINISTRATOR:	EHIMAMIEGHO, JUSTICE OSASE		FACILITY TYPE:	740
ADDRESS:	407 MAPLE STREET		TELEPHONE:	(916) 912-8042
CITY:	GALT	STATE: CA	ZIP CODE:	95632
CAPACITY:	18	CENSUS: 15	DATE:	02/23/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Caregiver Stephanie Siewe Ehimamiegho		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Licensee did not report to the licensing agency within the agency's next working day and a written report should be submitted to licensing within seven days following the occurrence of such event.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Renee Campbell and Licensing Program Manager Liza King, made an unannounced visit to Ehimas to deliver the findings of a complaint investigation. LPA Campbell discussed the purpose of the visit and the elements of the allegation with Caregiver Stephanie Siewe Ehimamiegho

During the investigation, LPA collected Resident #1’s (R1) physician report, staff notes, incident reports, needs and service plan and admission agreement. LPA also interviewed the administrator and five collaborating agency personnel. Based on Incident reports, Administrator did report prior visits of R1 to the hospital and when R1 was placed on 5150. The visits that occurred on 10/11/22, 12/03/22 and 12/07/22 were reported and submitted to licensing as required.

This agency has investigated the complaint alleging that the licensee did not report incidents to the licensing agency . We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.
No deficiencies, Exit Interview Conducted.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Renee Campbell	TELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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