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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700903
Report Date: 10/14/2024
Date Signed: 10/14/2024 12:53:31 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
06/25/2024 and conducted by Evaluator Christina Valerio
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240625121040
FACILITY NAME:EHIMAS RESIDENTIAL CAREFACILITY NUMBER:
342700903
ADMINISTRATOR:STEPHANIE SIEWEFACILITY TYPE:
740
ADDRESS:407 MAPLE STREETTELEPHONE:
(916) 912-8042
CITY:GALTSTATE: CAZIP CODE:
95632
CAPACITY:15CENSUS: DATE:
10/14/2024
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Stephanie SieweTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff are mismanaging resident's medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver complaint findings. LPA Valerio met with facility staff Eliakil Gargadi, and explained the purpose of the visit. LPA was later met by Administrator Stephanie Siewe.

According to the RP, RP stated that the staff were told by Administrator Stephanie to stop giving a resident a certain medication. RP stated that there is no doctors order that says to stop the medication. On 10/14/2024, LPA Valerio observed Medication Administrator Records (MAR) for six (6) residents. Orders on the MAR matched the doctors orders and the bubble packs for 5 out of 6 residents. 6 out of 6 resident MARs were observed to have missing signatures for 10/13/2024 and AM shift on 10/14/2024.
Based on records review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Per California Code of Regulation- Title 22 deficiencies are being cited. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was conducted, and a copy of the report was left at the facility.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024
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 6
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
06/25/2024 and conducted by Evaluator Christina Valerio
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240625121040

FACILITY NAME:EHIMAS RESIDENTIAL CAREFACILITY NUMBER:
342700903
ADMINISTRATOR:STEPHANIE SIEWEFACILITY TYPE:
740
ADDRESS:407 MAPLE STREETTELEPHONE:
(916) 912-8042
CITY:GALTSTATE: CAZIP CODE:
95632
CAPACITY:15CENSUS: DATE:
10/14/2024
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Stephanie SieweTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff did not prevent resident from threatening another resident
Staff handled resident in a rough manner
Staff yells at residents
Staff left resident in soiled diapers for an extended period of time
Staff did not ensure the facility was free from odors
Staff are not allowing residents to have water
Staff did not ensure the facility was free from pests
Staff did not ensure the facility bathroom was not in disrepair
Staff are not providing a comfortable temperature for residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver complaint findings. LPA Valerio met with facility staff Eliakil Gargadi, and explained the purpose of the visit. LPA was later met by Administrator Stephanie Siewe.

The following has been determined as it relates to abovementioned allegations.

Staff did not prevent resident from threatening another resident

According to the Reporting Party (RP), it was reported that a resident threatened another resident by saying they were going to slice up Resident 6 (R6) because R6 is always in their business. LPA Valerio observed the residents in care on 07/02/24 and 08/08/24. LPA did not observe a resident that matched the description provided by the RP. On 08/08/24, LPA interviewed R6. R6 reported no one has threatened R6 before and if they did R6 would yell at them.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 27-AS-20240625121040
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: 10/14/2024
NARRATIVE
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Staff handled resident in a rough manner
According to the RP, it was reported that on 06/06 or  06/07 a staff member body slammed a resident onto their bed because they did not know how to put down the grab bars. The alleged resident is on hospice and is unable to communicate. LPA Valerio interviewed the resident's roommate, Resident 5 (R5). However, R5 was unable to provide information related to the allegation. According to an interview with Staff 2 (S2), staff appear to be gentle with the resident. LPA Valerio reviewed the staff schedule for June 2024. LPA did not observe a staff member name that matched the name provided by the RP.

Staff yells at residents
LPA Valerio interviewed six (6) residents. R1 stated staff do not yell at us, they are nice people. R2 did not report any staff yelling at R2. R3 reported that staff are okay and they do not yell at R6 or anyone. R4 had nothing to complain about. R5 was unable to convey if staff yell or do not yell at residents. R6 reported that staff do no yell at R6. Based on interviews with three staff members (S1, S2, and S3), all staff reported that they do not raise their voice or yell at any of the residents.

Staff left resident in soiled diapers for an extended period of time / Staff did not ensure the facility was free from odors
According to the RP, the facility smells like ammonia due to the residents being soaked for hours from the day shift. LPA attempted to gather additional information from the RP; however, RP told LPA to go to the facility and observe it herself. LPA Valerio observed the facility on 07/02/24 and 08/08/24. During both visits, LPA Valerio did not observe any odors resulting from incontinence. LPA Valerio interviewed residents. R1 reported that staff do their rounds about 30 to 49 minutes for each resident. When R1 asks for help, R1 receives help right away. R1 reported that R1 only needs to be checked every couple of hours. R3 reported that staff are supposed to change R3's diaper; however, R3 prefers to do it themselves because they can. R5 was unable to convey if staff assist R5 with ADLs; however, LPA did not observe any signs of soiled clothing or odors. According to an interview with S1, S1 reported S1 checks on them about every hour because R1 does not want them to get a rash. According to an interview with S3, S3 reported that a noc shift staff was fired because she was caught sleeping.  The staff member was an employee for a few weeks. S3 came to the facility to check on the staff. When S3 arrived, the staff was observed sleeping and did not notice S3 come in. After S3 was fired, the staff started to blame other staff for tasks that she failed to complete.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 27-AS-20240625121040
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: 10/14/2024
NARRATIVE
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Staff are not allowing residents to have water

According to the RP, RP has observed a resident asking for water and another staff member will say "no! go to bed!". LPA attempted to obtain additional information from the RP; however, the RP refused to provided additional information. LPA Valerio observed the facility on 07/02/24 and 08/08/24. During both visits, LPA observed staff providing residents water, juice, or their request beverage of choice. S1 was observed getting up from the interview to provide a resident request for additional water. According to an interview with S2, the facility has a water dispenser located in the middle of the kitchen, which they used to have  outside the kitchen. There was a resident that would dump the whole dispenser on the floor. Staff provide water ever hour, but the residents hate water. To help, the facility will add flavored water, which the residents enjoy.

Staff did not ensure the facility was free from pests

According to the RP, the facility has water bugs located all over the facility. During LPA's visits on 07/02/24, 08/08/24, and 10/14/24,  there was no evidence of water bugs or other pest located in the facility. According to an interview with S2, the facility has a monthly pest control service that comes every month. S2 reported that they can be contacted as needed if anyone sees pest. LPA observed pest control invoices for April, June, and August of 2024.

Staff did not ensure the facility bathroom was not in disrepair

LPA Valerio observed the facility on  07/02/24 and 08/08/24. Residents have access to two out of three bathrooms. The bathroom located closest to the front door has multiple stalls, a sink, and shower to use. The second bathroom located in the middle of the hallway has one toilet, one sink, and one shower. Both restrooms were observed to be in working condition. The third bathroom is considered a staff bathroom. In order to get in, staff use a key. Based on an interview with S1, the bathroom used for staff works; however, you need to use a bucket of water to flush the toilet. According to an interview with S2, all the bathrooms work. Based on the an interview with Administrator Stephanie, the staff bathroom is currently working and you do not need a bucket to flush it.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 27-AS-20240625121040
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: 10/14/2024
NARRATIVE
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Staff are not providing a comfortable temperature for residents

According to the RP, the licensee refuses to turn on the air conditioning. RP observed residents with sweat dripping down their face from it being so hot. On 07/02/24, LPA Valerio observed the front window located in the front common living room to be open. LPA Valerio observed the facility thermostat, which read a temperature of 85 degrees Fahrenheit. The temperature outside the facility upon arrival was 101.0 degree Fahrenheit and the city of Galt issued an excessive heat warning due to the temperatures rising up to 110.0 degree Fahrenheit. At 3:00 PM, the thermostat read 81 degrees and the temperature outside of the home was 108 degrees. LPA received notification of the facility temperature: 07/03/2024 at 3:00 PM - 78 degrees Fahrenheit, 07/04/2024 at 12:45 PM - 73 degrees Fahrenheit , 07/05/2024 at 9:57 AM - 70 degrees Fahrenheit, 07/05/2024 at 1:44 PM - 73 degrees Fahrenheit. On 08/08/24, the facility thermostat was set to 73 degrees Fahrenheit while fans were observed in resident bedrooms and the common hallway.
 
Due to the above noted information, although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated. Per California Code of Regulations (CCRs) - Title 22, no deficiencies cited. An exit interview was held and a copy of report was left at the facility with Administrator Stephanie Siewe.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20240625121040
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: 10/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/15/2024
Section Cited
CCR
87465(e)
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87465 Incidental Medical and Dental Care (e)For every prescription and nonprescription PRN medication...there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. This requirement not met as evidenced by:
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The licensee will provide a plan on how to ensure medications are signed off timely by staff and ensure medications orders are up to date. LPA to receive plan by POC due date 10/15/2024.
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Based on records review, the licensee did not ensure 1 out of 6 resident files reviewed had a written order for a PRN located in the CSML and the MAR.
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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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6