342700903-3-20-2023-27-AS-KHOS-CU5QG6-20230727120854

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700903
Report Date: 03/20/2023
Date Signed: 03/20/2023 01:10:57 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
03/03/2023 and conducted by Evaluator Maja Jensen

COMPLAINT CONTROL NUMBER: 27-AS-20230303123659

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:	DATE:	03/20/2023
		UNANNOUNCED	TIME BEGAN:	10:33 AM
MET WITH:			TIME COMPLETED:	01:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is not clean
Facility is malodorous

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 3/20/23 at approximately 10am Licensing Program Analysts (LPAs) Maja Jensen and Jennifer Fain arrived at facilty unannounced to continue an investigation into the above listed allegations. LPAs Jensen and Fain met with Stephanie Siewe.

LPA Jensen and Fain toured the facility including grounds, dining room, kitchen, bathrooms and resident rooms. LPA Jensen observed 1 of 2 refrigerators were malfunctioning. Upon entering the kitchen, the refrigerator on the left hand side nextb to the office was approximately 55 degrees. The refrigerator contained left over food in a carry out container, soda, cookies. The refrigerator was sticky to the touch. The freezer contained juice and milk. The contents of the freezer were not frozen and the freezer was observed to be slightly cooler the refrigerator portion. LPA Jensen also observed rust and broken rubber seals around the preimeter of the refrigerator. Photos were taken.

Continued on LIC 9099C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023

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-20230303123659

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: 03/20/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA Jensen interviewed care provider Stephanie Siewe. She stated that sometimes the refrigerator functions properly and sometimes it does not. When the Administrator is present he can usually set the circuit breaker in order to make it function properly. LPA Jensen instructed care provider and cook to discard all food product from the malfunctioning refrigerator.

LPA Jensen interviewed 3 residents and 1 responsible party. 2 residents were interviewed in their rooms and 1 resident and one responsible party was interviewed outside.

LPA Jensen observed stains on the walls in a bedroom and chewed sunflower shells behind a night stand in the same room. LPA Jensen also observed a discarded mattress and damaged chairs being stored in the back yard. LPA Jensen attempted to interview a resident in a resident bedroom privately but was unable to shut the door as it was broken. The door was either out of alignment or had expanded beyond the size of the door frame and would not shut properly. LPA Jensen observed blood on the linen of resident sheets and pillow case. In the dining room by the wall with the clock, on the floor next to the hallway LPA Jensen observed approximately 20 half inch diameter stains on the floor and food remnants.

LPA Jensen detected an odor of urine emanating from a residents room. LPA Jensen also detected an odor of urine during the course of site visits on 3/6/23 and 3/9/23.

Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report and appeal rights were provided to care provider Stephanie Siewe.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20230303123659

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: 03/20/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/23/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The Licensee will submit a plan by 3/23/23 to maja.jensen@dss.ca.gov to come in to compliance with this regulation by 3/27/23.
	8 9 10 11 12 13 14	Based on LPA Jensen's observation of chewed sunflower seed shells on floor, stains on walls, stains on floor, broken bedroom door and discarded mattress and chairs in backyard. This poses a potential risk to the health, safety and personal rights of residents in care.	8 9 10 11 12 13 14
Type B 03/23/2023 Section Cited CCR 87625(b)(3)	1 2 3 4 5 6 7	...the licensee shall be responsible for the following: ... Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.	1 2 3 4 5 6 7	The Licensee will submit a plan by 3/23/23 to maja.jensen@dss.ca.gov to come in to compliance with this regulation by 3/27/23.
	8 9 10 11 12 13 14	Based on LPA Jensen's detection of an odor related to urine or feces on 3 separate occasions. This poses a potential risk to the health, safety and personal rights to residents in care.	8 9 10 11 12 13 14

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 King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3