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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700903
Report Date: 02/23/2023
Date Signed: 02/23/2023 01:24:52 PM

Substantiated


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
01/18/2023 and conducted by Evaluator Renee Campbell
COMPLAINT CONTROL NUMBER: 27-AS-20230118092636
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:
02/23/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Caregiver Stephanie Siewe EhimamieghoTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility staff does not properly store/prepare food.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Renee Campbell and Licensing Program Manager (LPM) Liza King arrived at the facility at 10:54 am to follow up on a complaint investigation. LPM met with a staff member and toured the facility including the resident bathroom, kitchen, 4 resident rooms.

LPM observed 3 days of perishables including fruits and vegetables. Frozen items included one item in a garbage bag which resembled beef, unlabeled, with ice chips and exposed meat, another item which appeared to be beef, one package of chicken, one pork roast exposed to the freezer with packaging damaged and meat appeared dry and another pork roast packaged appropriately. In the refrigerator there were 4 containers ranging in size that were unlabeled. Several jarred containers were opened without an opened label.

Based on todays observations this allegation is substantiated meaning, the preponderance of evidence standard has been met. Citations were issued and appeals rights were provided during an exit interviiew with Caregiver Stephanie Siewe Ehimamiegho..
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 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)
Page: 1 of 2
Control Number 27-AS-20230118092636
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: 02/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/03/2023
Section Cited
CCR
87555(9)
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87555 general food services Procedures which protect ... food shall be observed in food storage, preparation and service.


This requirement is not met as evidenced by
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Facility will correctly packege food items with dates and a description of the item by POC date.
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Based on observation, interviews and record review freezer burned food, opened packages of frozen meat and unlabeled food item were found in the refrigerator and freezer.
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CCR
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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: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2