342700903-4-28-2023-27-AS-MJEN-CRBUPU-20230428154608

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700903
Report Date: 04/28/2023
Date Signed: 04/28/2023 03:46:17 PM

Document Has Been Signed on 04/28/2023 03:46 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 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: 13	DATE:	04/28/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Justice Ehimamiegho		TIME COMPLETED:	04:00 PM

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On 4/28/23 at approximately 3:15pm Licensing Program Analysts (LPAs) Maja Jensen and Jennifer Fain arrived at facility unannounced to conduct a case management in order to follow up on action items identified during the legal/non-compliance conference held on 4/12/23. LPA Jensen met with Licensee Justice Ehimamiegho and explained the purpose of today's visit. The following updates were obtained:

Licensees stated they will do the following to achieve continued and substantial compliance (updates are in BOLD text):
· Immediately identify 2 medical transports companies in the area to provide non-emergency transport-AMR and CMS were contacted, they advised no contract is needed and that services can be requested as needed

· Immediately ensure Administrator presence for a minimum of 40 hours a week-Stephenie Siewe will submit Administrators certification application no later than Monday May 1, 2023 and until then Licensee is at facility 40 hours a week and has a current certification.

· Immediately refrain from accepting or retaining residents determined by a physician to have a primary diagnosis of a mental disorder unrelated to dementia-Immediately complied with

· The licensee will evaluate the current STD850 to ensure that they are in compliance with the state Fire Marshall; The facility has a non ambulatory fire clearance for each room that will be used to accommodate a resident with dementia within 2 days; submit an updated LIC200 and facility sketch.-Email sent to LPA Jensen within the required time frame.

Continued on LIC 809C....

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: 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)

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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
	VISIT DATE: 04/28/2023

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· Submit a new LIC 500 by 04/17/23
· Submit an Activity Calendar within 2 days
· In 7 days comply with all regulations specific to facilities licensed for a capacity of 16 or greater OR seek a decrease in capacity
· Conduct a self assessment of all resident and personal files within 30 days and make needed updates per requirements.
· Have all food preparation staff ServSafe certified within 30 days.
· Utilize an off site training for Mandated Reporting and de-escalation within 30 days
· Engage the residents in the menu process within 30 days and document preferences.
· Assess and replace mattresses and/or waterproof mattress sleeves within 90 days.
· Review and Amend the current incontinence plan to be approved by the Department within 90 days.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: 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

LIC809 (FAS) - (06/04)

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