342700903-2-23-2023-27-AS-KHOS-CPPS8X-20230307123946

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700903
Report Date: 02/23/2023
Date Signed: 02/23/2023 11:30:08 AM

Unsubstantiated

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:	DATE:	02/23/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Caregiver Stephanie Siewe Ehimamiegho		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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The licensee did not mail or fax to the Department a copy of the 30-day written notice in accordance with (a) above within five days of giving the notice to the client.

INVESTIGATION FINDINGS:

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At approximately 11:00 am on 02/23/23, 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 and needs and service plan. LPA also interviewed the administrator and five collaborating agency personnel. Although W1 informed the regional office that the administrator reported that he did not want the resident to return to the facility following R1’s 5150 hold, interviews with four other collaborating agency staff members including mental health, placement and payee service, were unable to corroborate the allegations of W1.
Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
No deficiencies, Exit Interview Conducted.

Unsubstantiated

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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