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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700903
Report Date: 08/17/2023
Date Signed: 08/17/2023 05:21:44 PM


Document Has Been Signed on 08/17/2023 05:21 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
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:
(916) 912-8042
CITY:GALTSTATE: CAZIP CODE:
95632
CAPACITY:15CENSUS: DATE:
08/17/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Justice EhimamieghoTIME COMPLETED:
05:30 PM
NARRATIVE
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On 8/17/23, Licensing Program Analyst, (LPA) Maja Jensen arrived at facility unannounced to conduct a case management for deficiencies. LPA Jensen met with Justice Ehimamiegho and explained the purpose of today's visit.

The Department conducted an investigation in relation to complaint control # 27-AS-20230227143013. During the course of that investigation and based on facility records it was determined Resident 1 (R1) fell on 11/19/2022, 11/29/2022, 12/16/2023, 12/24/2023, and 02/23/2023. Paramedics assessed R1 after the fall on 12/16/2023, but R1 was not taken to the hospital. Consumnes Fire Department Report #F202220234263 documents that facility staff S1 signed the Patient Care Report and acknowledged refusal of transport. S1 reported that the paramedics refused to transport Gregory to the hospital and that she was not the one to make the decision to not send R1 to the hospital however the Consumnes Fore Department Pre hospital Care Report states " staff signed against medical advice and witnessed via crew. No further patient care provided and crew cleared scene" R1 was not assessed at the hospital until after the fall on 02/23/2023.

The resident's needs and service plan is dated 12/9/22 and was not updated after the fall from 12/16/23 or 12/24/23 despite the fact that fall prevention measures that the Administrator claims were in place were ineffective.

Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of Civil Penalties.

An exit interview was conducted and a copy of this report, a confidential names list and appeal rights were provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023
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 2


Document Has Been Signed on 08/17/2023 05:21 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
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: 08/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
08/18/2023
Section Cited
CCR
87465(a)(1)

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Incidental Medical and Care
...The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not as evidenced by:
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The Licensee agrees to send a signed attestation that this regulation has been read, understood and will be complied with to maja.jensen@dss.ca.gov by bPOC due date.
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Based on the Consumnes Fire Department, Prehospital Care Report #F22234263, S1 signed an order for R1 not to be transported to the Emergency Department against medical advice. This poses an immediate risk to the health, safety and personal rights of residents in care.
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Request Denied
Type A
08/17/2023
Section Cited
CCR87463(a)

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Reappraisals
The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. This requirement was not met as evidenced by:
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The Licensee agrees to send a signed attestation that this regulation has been read, understood and will be complied with to maja.jensen@dss.ca.gov by bPOC due date.
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Based on records reviewed the resident appraisal was not updated after R1 sustained multiple signficant falls. This poses an immediate risk to 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: 08/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2