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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700903
Report Date: 07/18/2023
Date Signed: 07/18/2023 03:29:19 PM


Document Has Been Signed on 07/18/2023 03:29 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
SACRAMENTO AC/SC, 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: 13DATE:
07/18/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Stephanie SieweTIME COMPLETED:
04:00 PM
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On 6/18/23 at approximately 11:00am LPA Jennifer Fain met LPA Maja Jenson at the residence unannounced to continue a complaint investigation. LPAs met with Stephanie Siewe and explained the purpose of the visit.

LPA Fain requested and received copies of the May and June employee schedule.

LPA Fain requested payroll records from May 2023 and June 2023 be emailed to Jennifer Fain at jennifer-fain@dss.ca.gov by Friday, July 28, 2023.

This investigation will take additional time to complete. An exit interview was conducted with Stephanie Siewe and a copy of this report was given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jennifer FainTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023
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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