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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700903
Report Date: 11/30/2022
Date Signed: 11/30/2022 04:25:30 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
08/22/2022 and conducted by Evaluator Renee Campbell
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220822135344
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: 14DATE:
11/30/2022
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Justice Osase EhimamieghoTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Resident sustained unexplained bruising while in care.
INVESTIGATION FINDINGS:
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On 11/30/2022 at 9:00 am, LPA Campbell and LPA Bilger came to facility unannounced to continue a complaint on the allegations noted above. LPA’s met with Justice Osase Ehimamiegho and explained the purpose of the visit. Allegation states resident received an unexplained injury while in care. LPA reviewed the following documents: 911 call logs, police reports and requested 602 for Resident 2(R2) as well as needs and service plan for R2. LPA also interviewed R1 , police, family and administrator Justice Osase Ehimamiegho.
When questioned by the police, resident denied having a desire to hurt himself on the date of the incident on 8/19/2022.
Based on staff statements and resident records, R2 has a history of banging his head into the wall and did sustain an injury on 8/19/22 that was observed by staff. Additionally, based on review of needs and service plan for R2 dated 8-7-22, facility staff identified R2's behavior of constantly banging head on wall with intervention to include 1:1 observation
cont. to LIC9099-C
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: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022
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 3
Control Number 27-AS-20220822135344
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
VISIT DATE: 11/30/2022
NARRATIVE
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cont from LIC9099. Based on LPAs observations, interviews, and record reviews, there is a preponderance of evidence to conclude that R2 sustained unexplained injuries while in care due to lack of appropriate monitoring of R2's needs, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An immediate civil penalty of $500 is issued in addition to citation issued. .
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20220822135344
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: 11/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
12/01/2022
Section Cited
HSC
1569.321(e)
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1569.321(e) Every facility...shall provide at least the following basic services: (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety and well-being.
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Licensee will audit all resident charts and current staffing schedules to ensure adequate monitoring and supervision of resident needs. Licensee will submit a completion date for audit by POC due date. Audit to completed no later than 2 weeks from date of citation issuance.
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Based on interviews and record reviews, the license did not provide the 1:1 observation requirement per the needs and services plan. This poses a potential Health, Safety or Personal Rights risk to persons 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: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3