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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700903
Report Date: 08/25/2023
Date Signed: 08/25/2023 05:24:13 PM


Document Has Been Signed on 08/25/2023 05:24 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:
08/25/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Stephanie SieweTIME COMPLETED:
03:45 PM
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On 8/25/23 at approximately 2pm Licensing Program Analysts (LPAs) Jennifer Fain and Maja Jensen arrived unannounced to collect documents for a comprehensive quarterly visit. LPAs met with Stephanie Siewe and explained the reason for the visit.

On arrival residents were observed in the living room watching tv, congregating in the hallway and resting in their rooms. The kitchen was observed to be sanitary. Dinner was prepped for tacos.

Based on the Non Compliance Conference on 4/12/23 the following areas will be assessed:
· The Administrator is present for a minimum of 40 hours a week *** August schedule requested and received.

· The licensee has not accepted any residents determined by a physician to have a primary diagnosis of a mental disorder unrelated to dementia *** Physicians' reports for residents admitted after 4/12/23 requested and received.

· The licensee ensured that they are in compliance with the state Fire Marshall; The facility has a non ambulatory fire clearance for each room that will be used to accommodate a resident with dementia *** 602s requested for all residents. Facility will email by Wednesday, 8/30/23.

· Meals were not observed during the visit.



LPA Fain will return after all documents are received and reviewed for the Quarterly Health and Safety Check. No Deficiencies were cited during today's visit.

An exit interview was conducted and a copy of this report was provided to Licensee.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jennifer FainTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2023
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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