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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700903
Report Date: 09/14/2023
Date Signed: 09/14/2023 03:37:41 PM


Document Has Been Signed on 09/14/2023 03:37 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: 13DATE:
09/14/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Stephanie SieweTIME COMPLETED:
03:00 PM
NARRATIVE
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On 9/14/23 at approximately 1:40 pm Licensing Program Analyst Jennifer Fain and Licensing Program Manager Liza King arrived at the facility to conduct a follow up Legal Noncomplaince Case Management Visit from 8/25/23. LPA and LPM met with Stephanie Siewe and explained the reason for the visit.

On 8/30/23 LPA Fain received requested documents: 602s for all residents and the facility sketch.

During the Informal Meeting on 4/12/23 the licensee agreed to “evaluate the current STD850 to ensure 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 within 2 days; submit an updated LIC200 and facility sketch.”

Based on the 602’s supplied for the residents, the facility sketch, and rooms the residents are staying in (provided by S1 on 8/25/23), there are 8 non-ambulatory residents, 4 of them are in ambulatory rooms.

Also, during the Informal meeting, the Licensee agreed to “Conduct a self-assessment of all resident and personnel files within 30 days and make needed updates per requirements.”

Based on the 602’s received 4 of 6 are past the due date for the required one year health evaluation.

LPA requested Discharge papers for R1 from hospital visit on 8/5/23 and related SIR.
LPA requested Incident Reports and discharge papers for R2 for the months of June, July and August 2023.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jennifer FainTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


Document Has Been Signed on 09/14/2023 03:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: EHIMAS RESIDENTIAL CARE
FACILITY NUMBER: 342700903

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2023
Section Cited
CCR
87705

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Care of Persons with Dementia (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by:
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Administrator will email a plan of correction by 9/15/23 to jennifer.fain@dss.ca.gov
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Based on record review of the 602s provided, the licensee did not ensure residents’ health records were up to date which poses a potential Health, Safety, and Personal Rights risk to persons 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: Jennifer FainTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 09/14/2023 03:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: EHIMAS RESIDENTIAL CARE
FACILITY NUMBER: 342700903

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/15/2023
Section Cited
CCR
87204

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Limitations - Capacity and Ambulatory Status (b) Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nonambulatory shall not remain in rooms restricted to ambulatory residents. This requirement is not met as evidenced by:
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Administrator will email a plan of correction by 9/15/23 to jennifer.fain@dss.ca.gov
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Based on observation, interview, and record review, the licensee did not ensure nonambulatory residents were housed in nonambulatory rooms which poses an immediate Health, Safety, and Personal Rights risk to persons 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: Jennifer FainTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: EHIMAS RESIDENTIAL CARE
FACILITY NUMBER: 342700903
VISIT DATE: 09/14/2023
NARRATIVE
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A civil penalty of $500 is being issued during today's visit for violation of California Code of Regulations Title 22 Section 87204(b). The facility is not in compliance with Title 22 Regulations, the deficiencies can be found on the LIC 809-D page.

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

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jennifer FainTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4