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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700903
Report Date: 08/25/2023
Date Signed: 08/25/2023 05:25:49 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/30/2023 and conducted by Evaluator Jennifer Fain
COMPLAINT CONTROL NUMBER: 27-AS-20230530132443
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
UNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Stephanie SieweTIME COMPLETED:
05:45 PM
ALLEGATION(S):
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Facility staff are not adequately supervising resident while in care.
INVESTIGATION FINDINGS:
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On 8/28/25 at approximately 3:45pm Licensing Program Analysts (LPAs) Jennifer Fain and Maja Jensen arrived at facility unannounced to deliver findings for a complaint investigation related to the above listed allegation. LPAs met with Facility Manager Stephenie Siewe and explained the purpose of today's visit.

LPA Fain reviewed Galt Police Department incident report #2305190056, dated 5/19/23, which states that an unknown female entered a residence without permission. The responding officer located resident 1 (R1) near the residence. The officer was familiar with R1 from previous contacts. The responding Officer returned R1 to the care home and into Staff 1’s (S1) care.
R1 has a history of elopement. Review of the Physician’s report for R1 states the resident may leave the facility unaccompanied. On 7/18/23 Licensee reported he had begun the process of updating the Physician’s Report and having R1 conserved. LPA was unable to interview R1 as resident was hospitalized and had not returned to the facility.
Continued on LIC 9099C...
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20230530132443
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/25/2023
NARRATIVE
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Document Link IconContinued from LIC 9099....
Based on Galt Police Department incident report #2305190056, R1 Physician’s report, prior Case Managements at this facility and Incident reports faxed to Community Care Licensing, as well as interviews with the Administrator and Staff 1, the allegation of Facility staff are not adequately supervising resident while in care is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met.

Deficiencies are being cited from California Code of Regulations Title 22, Division 6. Failure to correct deficiencies may result in additional civil penalties and administrative action.

An exit interview was conducted, and a copy of this report, an LIC 811 and appeal rights were given to Stephanie Siewe.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20230530132443
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/25/2023
Section Cited
CCR
87468.2(a)(4)
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(a) … residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(4) 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.
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The Licensee agrees to write an attestation stating the above regulation has been read understood and will be complied with.
Resident needs a higher level of care and has moved to another facility.
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This requirement is not met as evidenced by:Based on interviews conducted and records reviewed, and the resident’s return by police officer, the licensee did not ensure the resident’s supervision needs were met, 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: 08/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
LIC9099 (FAS) - (06/04)
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