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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700903
Report Date: 04/08/2024
Date Signed: 04/08/2024 02:46:26 PM


Document Has Been Signed on 04/08/2024 02:46 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 13DATE:
04/08/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Stephanie SieweTIME COMPLETED:
03:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct a case management visit. LPA rang the door bell and was met by Resident 1 (R1). LPA introduced self and asked if any staff were present. R1 took LPA to staff. Staff was assisting another resident and mopping the floor. LPA introduced herself, and explained the purpose of the visit. LPA asked if Staff 1 (S1) was the only staff on shift. S1 was currently the only staff as Administrator Stephanie had a personal appointment.

LPA was approached by Resident 1 (R1), Resident 2 (R2), Resident 3 (R3), and Resident (4) upon arrival. LPA spoke to the residents and explained the purpose of the visit. LPA Valerio was met by Administrator Stephanie roughly five to ten minutes later. According to the Administrator, Administrator Stephanie is usually at the facility. LPA requested facility files. According to the staff schedule submitted by the facility Administrator, Administrator Stephanie is scheduled from 7:00 AM - 7:00 PM along with S1, which is on schedule from 7:00 AM - 3:00 PM. Based on observations and records review, the facility did not ensure there was a sufficient number of staff to meet the needs of the residents and did not follow their staff schedule. When LPA arrived there was 1 staff member to care for 13 residents.

LPA took a tour of the facility to ensure compliance of Title 22 regulations. LPA observed the facility food supply. LPA took pictures for reference. In the freezer, there was 2 loaves of bread, 3 small bags of frozen meat, and 9 small-medium freezer bags of unknown food items. The bags were labeled with a date but not what type of food in the bag. In the refrigerator, there were sauces and spices on the right door shelves, 1 large mayo container, 1 gallon of milk, 3 containers of left over food items, 2 large packages of meat, 2 bags of carrots, 1 bundle of celery, 3 bell peppers, and 7 tomatoes. In the shed in the back, there were frozen loaves of bread, 4 packs of frozen chicken, 1 large brisket, 1 family size beef. An emergency box of food were observed in the shed. For Lunch, the facility stated they were making tuna sandwiches made from the canned tuna and ravioli soup made from the canned ravioli. Based on LPA's observation, the facility did not ensure to have 2 days of perishable food items, such a fruit and vegetables.

Continues on LIC 809 - C...
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2024
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 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/08/2024
NARRATIVE
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Continued from LIC 809

LPA requested a copy of their LIC 9020 Register of Facility Clients/Residents. LPA requested 3 resident files from the list. LPA reviewed Resident 1 (R1), Resident 5 (R5), and Resident 6 (R6) files. 2 out of 3 files were observed to be incomplete. R1's file was observed to be complete with up to date information. R5's file was observed to be incomplete with a missing signature on the consent for medical treatment form. A Administrator Stephanie stated that R6's file is incomplete because the resident recently moved in. There was no admission agreement in the initial packet that Administrator Stephanie provided. LPA was provided the admission agreement, however, there were portions of the agreement that were not entirely filled out. According to R6's facility file. LPA did not observe a pre-placement appraisal or current appraisal on file. The file had an incomplete face sheet, incomplete admission agreement, Discharge Documents from previous placement, LIC 602 Physician's Report, and Medication Orders. R6 requires Oxygen daily. LPA observed R6's designated room. LPA did not observed oxygen in use signs at the door. TA was provided for the signs. According to the Licensee Justice, residents often rip the signs off from the door. LPA observed the oxygen tank and machine. According to the LIC 602, R6 is able to administer own oxygen.

LPA reviewed admission agreements with rental rates. Administrator Stephanie and Licensee Justice stated there are no residents that have received an increase in rental rate. There are two residents, R1 and R5, that are in discussion based on individual circumstances. Administrator and Licensee confirmed understanding of rental increases and stated they provide notices and request signatures prior to the increase. LPA provided Technical Assistance and advised to review Health and Safety Code 1569.655, which states "...the licensee shall provide no less than 60 days' prior written notice to the residents or residents' representative setting forth the amount increase..."

Per California Code of Regulations (CCR), Title 22, deficiencies are being cited on the attached LIC 809 - D page. Appeal rights were provided. An exit interview was held with Administrator Stephanie, and a copy of the report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/08/2024 02:46 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
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: 04/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/09/2024
Section Cited
CCR
87468.2(a)(4)

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87468.2 Additional Personal Rights of Residents ...(a) In addition to the rights Section 87468.1,...:(4)To care, supervision, ... 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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Administrator Stephanie arrived to the facility 10 minutes after LPAs arrival. Licensee stated he will submit a letter of acknowledgment and understanding of regulation 87468.2 and provide facility plans to ensure they follow their staff schedule.
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Based on observation and records review, LPA observed 1 staff on shift for 13 residents when two staff are scheduled to work for AM shift, which poses an immediate health and safety risk to residents in care.
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Type A
04/09/2024
Section Cited
CCR87555(b)(26)

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87555General Food Service Requirements (b) The following food service requirements shall apply: (26)Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement was not met as evidenced by:
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Licensee brought additional food supplies to the facility during LPAs' visit. Licensee to submit a plan of when food supplies will be restocked for April, May, and June by POC due date.
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Based on observations, the facility did not have a food supply of fruits and vegetables that met the above requirements during LPA's visit, which poses an immediate health and safety risk to 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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 04/08/2024 02:46 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
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: 04/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/10/2024
Section Cited
CCR
87506(a)

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87506 Resident Records (a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility... This requirement was not met as evidenced by:
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Licensee stated they will ensure they complete the files for the two residents. During the visit, Administrator completed R6's file. LPA to receive copies of completed documents by POC due date.
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Based on observations and records review, 2 out of 3 resident files were observed to be missing documentation. This poses a potential health, safety, and personal rights risk to 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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4