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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700903
Report Date: 01/05/2022
Date Signed: 01/05/2022 12:19:06 PM

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: 15DATE:
01/05/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Justice Osase Ehimamiegho, AdministratorTIME COMPLETED:
12:35 PM
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On 01/05/2022, Licensing Program Analyst (LPA),T. White, conducted an unannounced case management visit to follow up on an AWOL incident, which occurred on 12/27/2021. LPA met with Administrator, Justice Osase Ehimamiegho and explained the purpose of the visit.

LPA White reviewed the incident report submitted to CCLD on 12/28/2021. Based on incident report, Resident #1 (R1) attempted to leave the facility, but staff re-assured R1 that Administrator will talk to R1 in the morning. Staff used the bathroom then asked R1 to please hold on for a minute, but R1 left right before staff was out of the restroom. Staff looked around and immediately called 911. Police found R1 and brought R1 back to facility. Based on R1's Physician Report, R1 is able to leave unassisted. LPA confirmed the safety of the resident and reviewed how the facility is working with the resident to prevent further AWOLs.

No deficiencies were cited today.

Exit interview was 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: 01/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2022
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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