342700903-6-3-2021-27-AS-LKIG-C3VS4C-20210611133231

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700903
Report Date: 06/03/2021
Date Signed: 06/03/2021 01:53:29 PM

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
05/26/2021 and conducted by Evaluator Treana White

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210526095058

FACILITY NAME:	EHIMAS RESIDENTIAL CARE		FACILITY NUMBER:	342700903
ADMINISTRATOR:	EHIMAMIEGHO, JUSTICE OSASE		FACILITY TYPE:	740
ADDRESS:	407 MAPLE STREET		TELEPHONE:	(408) 791-9763
CITY:	GALT	STATE: CA	ZIP CODE:	95632
CAPACITY:	18	CENSUS: 17	DATE:	06/03/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Justice Ehimamiegho, Administrator		TIME COMPLETED:	02:05 PM

ALLEGATION(S):

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9

Facility failed to report resident AWOL

INVESTIGATION FINDINGS:

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13

On 06/03/2021, Licensing Program Analyst (LPA) T. White conducted an unannounced complaint investigation regarding the above allegation. LPA White discussed the purpose of the visit and the elements of the allegation with Administrator, Justice Ehimamiegho.

During the course of investigation, LPA collected Resident #1 (R1) physician report, staff notes, needs and service plan and received a ring video. Based on Staff #1 (S1), facility did not report resident AWOL because resident is able to leave unassisted. Based on LIC602, R1 is able to leave unassisted. However, S1 contacted law enforcement, R1's case manager and doctor. S1 stated incident was not reported to CCLD.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.
Exit interview with Administrator. Appeal rights and report given.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

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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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
05/26/2021 and conducted by Evaluator Treana White

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210526095058

FACILITY NAME:	EHIMAS RESIDENTIAL CARE		FACILITY NUMBER:	342700903
ADMINISTRATOR:	EHIMAMIEGHO, JUSTICE OSASE		FACILITY TYPE:	740
ADDRESS:	407 MAPLE STREET		TELEPHONE:	(408) 791-9763
CITY:	GALT	STATE: CA	ZIP CODE:	95632
CAPACITY:	18	CENSUS: 17	DATE:	06/03/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Justice Ehimamiegho, Administrator		TIME COMPLETED:	02:05 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Neglect/lack of supervision: Resident (R1) wandered outside due to lack of supervision

INVESTIGATION FINDINGS:

1
2
3
4
5
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7
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9
10
11
12
13

On 06/03/2021, Licensing Program Analyst (LPA) T. White conducted an unannounced complaint investigation regarding the above allegation. LPA White discussed the purpose of the visit and the elements of the allegation with Administrator, Justice Ehimamiegho.

On 05/26/2021, LPA White received a ring video showing Resident #1 (R1) sitting on a porch. Based on information provided, law enforcement was called and R1 returned back to the facility. Based on LIC602 dated 11/06/2020, R1 is able to leave unassisted. S1 stated facility contacted law enforcement because R1 was out of the facility"longer than usual".

This agency has investigated the complaint alleging Neglect/lack of supervision: Resident (R1) wandered outside due to lack of supervision. 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 cited during visit.
Exit interview conducted with Administrator. A copy of report given.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

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

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 27-AS-20210526095058

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/03/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 06/18/2021 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	87211(a)(1)(D):Reporting requirements (a) Each licensee...(1)A written report shall be submitted to the licensing agency and to the person responsible... (D)Any incident which threatens the any resident, such as...unexplained absence... This requirement was not met as evidence by:	1 2 3 4 5 6 7	Administrator agreed to provide training to all staff on Reporting Requirements, specifically AWOLS and submit proof to CCLD by POC date.
	8 9 10 11 12 13 14	Based on LPA documentation, facility did not comply with section 87211(a)(1)(D). Administrator stated the facility did not report incident to CCLD, which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

LIC9099 (FAS) - (06/04)

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