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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700903
Report Date: 07/19/2023
Date Signed: 07/19/2023 03:26:49 PM


Document Has Been Signed on 07/19/2023 03:26 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:
07/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Justice EhimamieghoTIME COMPLETED:
03:45 PM
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On 7/19/23 at approximately 9am Licensing Program Analyst (LPA) Maja Jensen and a department auditor arrived at facility for a scheduled visit to continue collecting data for a trust audit. LPA Jensen and the Department auditor met with Licensee Justice Ehimamiegho and Stephanie Siewe and explained the purpose of today's visit.

During the course of the visit the department auditor interviewed 7 of 12 residents. In addition the auditor scanned copies of the LIC 602 and admission agreement for residents 1 through 7 (R1-R7).

An exit interview was conducted and a copy of this report was handed to Stephanie Siewe.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2023
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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