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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700903
Report Date: 07/18/2023
Date Signed: 07/18/2023 04:16:58 PM

Unsubstantiated


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:
07/18/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Justice EhimamieghoTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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9
Staff is withholding resident's medications
INVESTIGATION FINDINGS:
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13
At approximately 10am on July 18, 2023 Licensing Program Analysts Maja Jensen and Jennifer Fain arrived at facility unannounced to continue a complaint investigation in to the above listed allegation. LPA Jensen met with Licensee Justice Ehimamiegho and explained the purpose of today's visit.

During the course of an interview with the Licensee, LPA Jensen was advised that medication is not witheld but rather the resident always requests medication early and the facility only administers medication a maximum of 1 hour early. During the course of a previous site visit made for the purposes of investigating the 14 allegations on this complaint, S1 complained to LPA Jensen that his medications were being withheld and he is in so much pain he can barely walk. It should be noted that S1 uses a walker. LPA Jensen checked theMedication Administration Record (MAR) and advised S1 that he still has 2 hours to go before his next dose but that the facility was willing to give him his medication an hour earlyContinued on LIC 9099C...





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: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023
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 5
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: 07/18/2023
NARRATIVE
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 S1 stated he cannot wait that long because he is pain and LPA Jensen asked him if he wants to go to the emergency room given that he is experiencing such a high level of pain. S1 stated he did not want to go to emergency room because it is too much waiting around. S1 then picked up his walker and walked to his room carrying his walker without incident.

While the Department was investigating other allegations related to S1 it was discovered that S1 has a history of making false allegations.

Based on LPA Jensen's review of the MAR, interview with the Licensee and LPA Jensen's direct interaction with S1 regarding the allegation, the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it.

No citations are being issued as a result of the investigation in to this allegation. A copy of this report and appeal rights were handed to the Licensee.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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:
07/18/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Justice EhimamieghoTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not meet the needs of residents in care
INVESTIGATION FINDINGS:
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13
At approximately 10am on July 18, 2023 Licensing Program Analysts (LPAs) Maja Jensen and Jennifer Fain arrived at facility unannounced to continue a complaint investigation in to the above listed allegation. LPA Jensen met with Licensee Justice Ehimamiegho and explained the purpose of today's visit.

During the course of a site visit on 3/20/23 LPA Jensen observed Resident 1 (R1) walking down the facility hall and bleeding from her arm. LPA Jensen alerted staff to this issue with R1 at which time staff attended to her needs. Also during the course of the visit LPA Fain observed meal service and witnessed Resident 2 (R2) eat a partial plate of food and leave the dining room. Resident 3 (R3) then went in to the dining room after R2 left and consumed R2's partially eaten plate. LPA Fain also witnessed a resident finishing another residents water glass. Based on LPA Jensen and Fain's observations the allegation of staff do not meet the needs of residents in care is SUBSTANTIATED. A finding of substantiated means that the preponderance of the evidence standard has been met.
Continued on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
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.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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: 07/18/2023
NARRATIVE
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Continued from LIC 9099...

Deficiencies are being cited from the California Code of Regulations (CCR). 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 handed to Administrator Justice Ehimamiegho.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
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
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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: 07/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/19/2023
Section Cited
CCR
87468.2(a)(4)
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Additional Personal Rights of Residents in Privately Operated Facilities
...residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:...
To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by:
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The Licensee has hired a 1:1 staff member for R1 as of May 2023. In addition the Licensee has reduced capacity in an effort to increase the quality of care. The Licensee also agrees to supervise residents during meal service effective immediately. Licensee will email an attestation to maja.jensen@dss.ca.gov regarding supervision of meal service by 7/19/23.
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Based on LPA Jensen's and Fain's observations of residents during the course of a site visit on 3/20/23 as described in the LIC 9099A. This poses an potential risk to the health, safety and personal rights of residents in care
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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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5