342700903-4-12-2023-27-AS-KHOS-CR8GV6-20230425054012

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700903
Report Date: 03/16/2023
Date Signed: 04/12/2023 03:12:58 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230118092636

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: 15	DATE:	03/16/2023
		UNANNOUNCED	TIME BEGAN:	02:54 PM
MET WITH:	Isaiah Trotter, Caregiver		TIME COMPLETED:	02:55 PM

ALLEGATION(S):

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Lack of supervision causing residents to AWOL.

INVESTIGATION FINDINGS:

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On 03/16/2023 at approximately 3 pm. Licensing Program Analyst (LPA) Renee Campbell arriveed unannounced to deliver findings for the complaint above. LPA met with Caregiver Isaiah Trotter and explained the purpose of the visit.

During the investigation, Licensing Program Analyst (LPA) Renee Campbell reviewed records for 2 residents in reference to 2 AWOL incidents. Facility provided 602, Needs and Services plans and the incident reports for both residents. Galt police provided call logs and/or police reports for the months of October to January and the responding officer was interviewed.

Of the two resident files reviewed, none were allowed to leave the facility unassisted. Only R2 left the facility without staff supervision. When R2 left the facility, he went to the bus stop alone. Staff were not reported to have gone with him. Per the responding officer, no staff were with the resident when he returned to the facility. The only staff on shift remained at the facility.

Cont
This record was amended and updated on 04/12/23.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Emerita Curiel	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee Campbell	TELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: EHIMAS RESIDENTIAL CARE	FACILITY NUMBER: 342700903
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/16/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 04/20/2023 Section Cited CCR 1569.312(d)	1 2 3 4 5 6 7	1569.312(d) - Basic Service Requirements. Every facility...shall provide at least the following basic services:(d) Being aware of the resident's general whereabouts…This requirement was not met as evidenced by	1 2 3 4 5 6 7	Licensee shall conduct in-service training with staff to go over how staff shall ensure that residents don't AWOL. Licensee shall submit the date for the training and send a signature sheet of all staff who attended to LPA by POC date.
	8 9 10 11 12 13 14	Based on review of police documentation for a found person(A missing person / found person on 01/10/23) This poses an immediate health and safety risk.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Emerita Curiel	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee Campbell	TELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

LIC9099 (FAS) - (06/04)

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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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: EHIMAS RESIDENTIAL CARE	FACILITY NUMBER: 342700903
	VISIT DATE: 03/16/2023

NARRATIVE

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This agency has investigated the complaint alleging that residents are AWOL due to lack of supervision. Based on interviews and a review of records, there was a lack of supervision for this resident. As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency(ies) cited on the LIC 9099-D, per Title 22 Regulations, Division 6 and a civil penalty is assessed.

Exit interview conducted. Copy of report, LIC 9099-D, and appeal rights provided. Failure to correct any deficiency(ies) by plan of correction due date(s) may result in civil penalties.

SUPERVISOR'S NAME: Emerita Curiel	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee Campbell	TELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

LIC9099 (FAS) - (06/04)

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