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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700903
Report Date: 10/13/2021
Date Signed: 10/13/2021 10:46:17 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:
10/13/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Justice Osase Ehimamiegho, AdministratorTIME COMPLETED:
11:00 AM
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On 10/13/2021, Licensing Program Analyst (LPA), T. White, conducted an unannounced case management visit to follow up on an incident submitted to CCLD on 10/06/2021. At approximately 9:30 AM, LPA met with Administrator, Justice Ehimamiegho at the entrance of the facility.LPA White's temperature was checked, logged, and then signed into the facility.

Based on incident report, on 10/04/2021, Resident #1 (R1) was transported to Kaiser hospital. Administrator spoke with Kaiser Care team regarding R1's needs and relocation to a higher level of care. The Kaiser team informed Administrator, higher level of care will not help R1. R1 is an adult and makes his own decisions.

Based on interview with Administrator, R1 was not eating at the facility and Administrator suggested R1 be relocated to higher level of care. The Kaiser team informed Administrator there is nothing a higher level of care will be able to do. Administrator stated R1 returned back at the facility on 10/06/2021 and has since been eating. On 10/13/2021, LPA observed R1 in the facility, watching television and eating.

No deficiencies cited during inspection.

Exit interview conducted with Administrator and a copy of report given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
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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