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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700903
Report Date: 04/28/2023
Date Signed: 04/28/2023 12:06:12 PM


Document Has Been Signed on 04/28/2023 12:06 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: 13DATE:
04/28/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Justice EhimamieghoTIME COMPLETED:
12:00 PM
NARRATIVE
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On 4/28/23 at approximately 9:30am Licensing Program Analysts (LPAs) Maja Jensen and Jennifer Fain arrived at facility unannounced to conduct a case management for a report related to a resident that left the facility unsupervised. LPAs Jensen and Fain met with Licensee Justice Ehimamiegho and explained the purpose of today's visit.

LPA Jensen was notified by local law enforcement that on 4/20/23 at approximately 4pm, resident 5 (R5) left the facility unsupervised. R5 was not reported missing until 08:23am on 4/21/23. At that time law enforcement canvassed the neighborhood and located the resident.

LPA Jensen also reviewed an incident report sent on 4/22/23 that indicated R5 left the facility on 4/20/23 after dinner and did not return until the next day after being found by the police.

LPA Jensen reviewed staff care notes that indicated R5 left the facility but no specifics were noted on where the R5 was going or when she would be back. LPA Jensen reviewed the resident sign out log and observed that R5 had signed out but there was no time of sign out or destination noted.

Deficiencies are being cited from the Health and Safety Code (HSC), Title 22, Division 6. An immediate $1000 civil penalty is also being assessed. Failure to correct deficiencies may result in additional civil penalties and administrative action.

An exit interview was conducted and a copy of this report was given.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 04/28/2023 12:06 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: 04/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/28/2023
Section Cited

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Basic services requirements
Every facility required to be licensed under this chapter shall provide at least the following basic services: ...
Being aware of the resident's general whereabouts, although the resident may travel independently in the community. This requirement was not met as evidenced by:
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The Licensee agrees to obtain a new physician's report to assess any changes in condition of the resident and to update the needs and service plan based on R5's current condition. Licensee will email LPA Jensen at maja.jensen@dss.ca.gov evidence that an appointment has been scheduled.
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Based on LPA Jensen's review of an incident report and the written account received by email from local law enforcement officer, resident R5 was outside of the facility and reported as missing from the afternoon of 4/20/23 to the morning of 4/21/23. This poses an immediate threat to the health, safety and personal rights of resident 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: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023
LIC809 (FAS) - (06/04)
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