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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700903
Report Date: 05/25/2023
Date Signed: 05/25/2023 01:09:27 PM

Unfounded


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 CAREFACILITY NUMBER:
342700903
ADMINISTRATOR:EHIMAMIEGHO, JUSTICE OSASEFACILITY TYPE:
740
ADDRESS:407 MAPLE STREETTELEPHONE:
(916) 912-8042
CITY:GALTSTATE: CAZIP CODE:
95632
CAPACITY:15CENSUS: DATE:
05/25/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:TIME COMPLETED:
11:00 AM
ALLEGATION(S):
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2
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9
Resident fell and sustained multiple injuries
Staff did not seek timely medical attention for resident
INVESTIGATION FINDINGS:
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2
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5
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13
.Licensing Program Analyst (LPA) Maja Jensen arrived at facility for a complaint investigation in to the above listed allegations. LPA Jensen met with Justice Ehimamiegho and explained the purpose of today's visit.

With respect to the allegation of resident fell and sustained multiple injuries due to neglect or a lack of care and supervision, staff were interviewed, clients were interviewed, Incident Reports reviewed, and medical records reviewed. It was determined that there was an unwitnessed fall on 2/26/2023, but Resident 1 was being appropriately supervised according to his care plan which does not state he needs checks at all. Staff were interviewed and disclosed they checked on Resident 1 twice between 1300 and 1600 hours on the date in question. At around 1630 hours, Resident 1 was found in his bed with bruising on his face and was sent to the hospital. Based on the interviews conducted and the records reviewed this allegation is UNFOUNDED. A finding of unfounded means the allegation is false, could not have happened or is without a reasonable basis.
Unfounded
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
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: 05/25/2023
NARRATIVE
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Continued from LIC 9099...
With respect to the allegation of staff did not seek timely medical attention for resident, staff were interviewed, clients were interviewed. In addition, Incident Reports were reviewed, and medical records were reviewed. It was determined that R1 had an unwitnessed fall 2/26/2026 but was being treated appropriately according to his care plan. Upon discovering R1's injuries, staff called paramedics and sent R1 to the hospital on 2/26/2023, minutes after discovering his injuries. Incident reports and medical records
support the chronology of events therefore the allegation of staff did not seek timely medical attention for resident is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened, or is without a reasonable basis.

An exit interview was conducted and a copy of this report and appeal rights were provided.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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 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
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Justice EhimamieghoTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Due to lack of staff supervision, resident had a physical altercation with another resident resulting in injury
Food is not prepared in a sanitary manner
Resident eloped without staff knowledge
INVESTIGATION FINDINGS:
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On 5/25/23 at approximately 11:00am Licensing Program Analyst (LPA) Maja Jensen arrived at facility for a complaint investigation in to the above listed allegations. LPA Jensen met with Justice Ehimamiegho and explained the purpose of today's visit.

LPA Jensen arrived at facility on 3/1/23 to address an unrelated matter. At that time Resident 6 (R6) and Resident 7 (R7) advised LPA Jensen that Resident 1 (R1) was assaulted by Resident 2 (R2) causing severe bruising to Resident 1's face. Staff and clients were interviewed and facility and hospital records were reviewed. No staff observed Resident 2 hitting Resident 1 with a fist or with an object. There were reports of yelling, but no physical contact made. The only client to witness the alleged assault was R6. Due to R6 being removed from 4 facilities in the span of 20 days, and reports from each facility claiming R6 was manipulative, violent, and untruthful, R6 was determined to be an unreliable witness.

Continued on LIC 9099C...
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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: 05/25/2023
NARRATIVE
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Continued from LIC 9099A...
The other clients who alleged the assault, got their information about the assault from R6. Their accounts were inconsistent, and none of the clients witnessed the incident themselves. The victim, R1, suffers from Dementia and does not recall the assault or the fall. Medical records were reviewed. R1 was seen on 2/26/2023 for the unwitnessed fall, and on 3/2/2023 after reports of being assaulted were made. According to the medical records there were no new injuries on 3/2/23 and no evidence to support he had been assaulted. As a result of the interviews conducted and the records reviewed the allegation of due to lack of staff supervision, resident had a physical altercation with another resident resulting in injury is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it.

LPA Jensen interviewed staff members, interviewed clients, reviewed law enforcement incident reports and facility records. It was determined that on multiple occasions residents have left the facility unassisted however there was no evidence found to support that residents left without staff knowledge. The facility maintains a sign out log for residents which does contain entries of residents leaving over the course of the last 3 months. The facility also maintains a log of notes regarding any unusual incidents and there were no entries observed for the year of 2023 that would indicate an elopement without staff knowledge. Based on the interviews conducted and the records reviewed the allegation of resident eloped without staff knowledge is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it.

LPA Jensen observed food preparation on 5/25/23, 4/28/23 and 3/20/23. LPA Jensen confirmed with site supervisor Stephanie Siewe that all staff completed ServSafe training in April and May. At this time all kitchen appliances are in good working order. There was no evidence of pest infestation observed. LPA Jensen asked kitchen staff to show LPA the cleaning supplies used for the kitchen and demonstrate cleaning protocol which was determined to be adequate. Based on observations made over the course of multiple visits the allegation of food is not prepared in a sanitary manor is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it.

An exit interview was conducted and a copy of this report and appeal rights were given.


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
LIC9099 (FAS) - (06/04)
Page: 4 of 4