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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700903
Report Date: 05/25/2023
Date Signed: 05/25/2023 01:22:02 PM


Document Has Been Signed on 05/25/2023 01:22 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:15CENSUS: 12DATE:
05/25/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Justice Ehimamiegho TIME COMPLETED:
01:30 PM
NARRATIVE
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On 5/25/23 at approximately 11:00am Licensing Program Analyst (LPA) Maja Jensen arrived at facility to conduct a case management for deficiencies observed during the course of complaint investigation #27-AS-20230303123659. LPA Jensen met with Justice Ehimamiegho and explained the purpose of today's visit.

On 3/21/23 at approximately 11:00am, a department investigator conducted an interview with Resident 9 (R9) and observed that R9 appeared unkempt with what was believed to be human feces on the side of his sweatpants.

Deficiencies are being cited from the California Code of Regulations. Failure to correct deficiencies may result in the assessment of civil penalties.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2023
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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Document Has Been Signed on 05/25/2023 01:22 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: 05/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/08/2023
Section Cited
CCR
87468.1(a)(1)

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Personal Rights of Residents in All Facilities

Residents in all residential care facilities for the elderly shall have all of the following personal rights:

(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by:
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Licensee agrees to conduct inservice training on pesonal rights by 6/8/23 and will email proof of completion to maja.jensen@dss.ca.gov
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Based on the Department investigator's observation of a R1 going about his daily routine with visibily soiled clothing. This poses a potential threat to health, safety and personal rights of residents 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: 05/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2023
LIC809 (FAS) - (06/04)
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