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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700903
Report Date: 10/01/2021
Date Signed: 10/01/2021 10:19:46 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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 CAREFACILITY NUMBER:
342700903
ADMINISTRATOR:EHIMAMIEGHO, JUSTICE OSASEFACILITY TYPE:
740
ADDRESS:407 MAPLE STREETTELEPHONE:
(408) 791-9763
CITY:GALTSTATE: CAZIP CODE:
95632
CAPACITY:18CENSUS: 17DATE:
10/01/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ricardo RodriguezTIME COMPLETED:
10:30 AM
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On 10/01/21, Licensing Program Analyst (LPA), Mohamed Filouane, conducted an unannounced case management visit to follow up on an AWOL incident, which occurred on 9/22/21. At approximately 9:55 AM, LPA met with staff member, Ricardo Rodriguez, at the entrance of the facility. LPA was sanitized following the facility's entrance health and safety procedures. LPA also had his temperature checked and logged and then signed into the facility.

LPA Filouane reviewed the incident report submitted to CCLD with the staff member. LPA confirmed the safety of the resident and reviewed how the facility is working with the resident to prevent further AWOLs. Staff stated that the facility employees have spoken with the resident in question to further prevent the resident from leaving the facility alone. According to facility staff, this resident has a history of attempting to go on walks to the store alone. The staff member stated that while working, they check the TV area every five to ten minutes to confirm all residents are present. The resident's roommate will also check on the resident in question, according to staff.

No deficiencies were cited today.

Exit interview was conducted with staff member Ricardo Rodriguez and a copy of this report was emailed to the Administrator.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Mohamed FilouaneTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2021
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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