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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700903
Report Date: 08/17/2023
Date Signed: 08/17/2023 05:26:53 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/27/2023 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20230227143013
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:
08/17/2023
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Justice EhimamieghoTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff neglect resulted in a resident sustaining multiple injuries while in care
INVESTIGATION FINDINGS:
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On 8/17/23, Licensing Program Analyst, (LPA) Maja Jensen arrived at facility unannounced to deliver findings in the complaint investigation related to the above listed allegation. LPA Jensen met with Justice Ehimamiegho and explained the purpose of today's visit.

During the course of the investigation the Department reviewed the Resident File for resident 1 (R1), the facility's daily note logs, medical records and pre-hospital care report. The Department also conducted interviews with R1, R1's family members, R1's case Telecare case worker, facility staff, facility residents and medical doctors involved in the R1's care.

On 02/23/2023, Resident 1 (R1) suffered a fall. As a result of the fall, R1 was transported to the
Emergency Room. R1 was assessed and was diagnosed with chronic rib fractures on his left and right side and two chronic transverse process fractures (spine).
Continued on LIC 9099C...
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20230227143013
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 08/17/2023
NARRATIVE
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Continued from LIC 9099....

The Doctor of Medicine (M.D. ) who reviewed R1’s computed tomography (CT) scan indicated that he could not definitively say when the injuries occurred or if they were a result of the same or different incidents. The M.D. stated that the fractures could have been a month to multiple months old and that they could have occurred at the same time or at different times. The M.D. stated that the cause of the fractures could have been falls, accidents, or direct blows.

R1 moved into the facility in September of 2022. Staff reported that R1 was a fall risk and that he
fell frequently. Records from the facility document that 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. R1 was not assessed at the hospital until after the fall on 02/23/2023.

According to facility staff and records, R1’s care plan was never updated after he suffered any of his
falls. Facility staff indicated that R1 was a fall risk beginning on the date of his admission. Fall
prevention measures included reminding R1 to use his wheelchair or walker as well as providing extra
visual supervision of him. Facility staff did not implement any other preventative actions to ensure that
R1 did not suffer further falls.

Based on records reviewed and interviews conducted the allegation of Staff neglect resulted in a resident sustaining multiple injuries while in care is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met.

As a result of this investigation, deficiencies are being cited from the California Code of Regulations, Title 22, Division 6 and a civil penalty for a repeat violation is being assessed. At the time of the complaint visit, the issuance of an additional Civil Penalty was still being determined and the licensee was informed that a civil penalty may be assessed based on Health and Safety Code § 1569.49.

An exit interview was conducted and a copy of this report, appeal rights and confidential names list was 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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20230227143013
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
87468.2(a)(4)
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Additional Personal Rights of Residents in Privately Operated Facilities
...residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
...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. This requirement was not met as evidenced by:
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The Licensee agrees to email an attestation to LPA at maja.jensen@dss.ca.gov that the regulation has been read, understood, and will be compiled with by the POC due date.
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Based on records reviewed and interviews conducted staff did not adequately supervise R1 resulting in multiple falls with serious bodily injury. This poses an immediate risk to the 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
LIC9099 (FAS) - (06/04)
Page: 3 of 3