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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700903
Report Date: 03/23/2022
Date Signed: 03/23/2022 12:53:10 PM


Document Has Been Signed on 03/23/2022 12:53 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
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: 14DATE:
03/23/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Administrator, Justice Osase EhimamieghoTIME COMPLETED:
01:05 PM
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On 03/23/2022, Licensing Program Analyst (LPA),T. White, conducted an unannounced case management visit to follow up on an AWOL incident, which occurred on 02/05/2022. LPA met with Administrator, Justice Osase Ehimamiegho and explained the purpose of the visit.

LPA White reviewed the incident report submitted to CCLD on 02/07/2022. Based on incident report, Resident #1 (R1) went out through the front door of the facility refusing to let staff know where he was going. Staff attempted to redirect him. R1 ignored every attempt of redirection and started running when he noticed that staff was coming towards him. R1 then made a right turn at the end of the street. Staff stopped walking towards him to avoid any further occurrence and called 911 at about 9am. Police found resident and brought him back to facility at 10am.Based on R1's Physician Report, R1 is able to leave unassisted. Administrator stated R1 was admitted to the hospital for surgery on 03/03/2022. LPA informed Administrator to contact CCL once R1 returns to the facility. LPA reviewed how the facility is working with residents 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: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2022
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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