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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700903
Report Date: 04/21/2022
Date Signed: 04/21/2022 03:48:51 PM


Document Has Been Signed on 04/21/2022 03:48 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:
(916) 912-8042
CITY:GALTSTATE: CAZIP CODE:
95632
CAPACITY:18CENSUS: 16DATE:
04/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Justice Osase Ehimamiegho, AdministratorTIME COMPLETED:
04:00 PM
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On 04/21/2022, Licensing Program Analysts (LPAs),T. White and R. Campbell conducted an unannounced case management visit to follow up on an AWOL incident, which occurred on 04/07/2022. LPAs met with Administrator, Justice Osase Ehimamiegho and explained the purpose of the visit.

LPAs White and Campbell reviewed the incident report submitted to CCLD on 04/13/2022. Based on the incident report, Resident #1 (R1) attempted to leave the facility. Staff told R1 that it was too late and attempted to redirect him. R1 stated he would be right back and walked out from the facility. When R1 did not return, staffed called police. Police later reported R1 was at Kaiser hospital. R1 returned to the facility the next morning. Per the physician's report, R1 is able to leave the facility unassisted.

Based on Administrator's interview, the Physician informed Administrator R1 needs more assistance and will be placed at a new facility. Based on observation, R1's belongings were removed from the facility. LPAs confirmed R1 arrived at new facility on 04/21/2022.

No deficiencies cited.

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: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022
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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