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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005264
Report Date: 07/28/2020
Date Signed: 07/28/2020 04:23:05 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:STAINLESS RESIDENTIAL CARE FACILITYFACILITY NUMBER:
347005264
ADMINISTRATOR:JUSTICE O EHIMAMIEGHOFACILITY TYPE:
740
ADDRESS:407 MAPLE STREETTELEPHONE:
(916) 821-2391
CITY:GALTSTATE: CAZIP CODE:
95632
CAPACITY:18CENSUS: 12DATE:
07/28/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Administrator Justice O EhimamieghoTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jason Lund contacted the facility to conclude a case management visit via telephone due to COVID-19 and pre-cautionary measures. A telephone call made to this facility on July 28, 2020 and this LPA was able to speak with the facility designated Administrator Justice O Ehimamiegho who was briefly interviewed. Current census was 12 residents. The LPA reviewed discharge records, incident reports and reappraisal. Interviews were conducted with the facility Administrator.

The purpose for the call is to discuss the facility retaining a Resident (R1) with a prohibited health condition without having an approved exception, not having a resident care plan from the Home Health agency and conducting a re-appraisal on R1 prior to R1 returning to the facility.

On July 14, 2020, the facility sent an incident report (LIC624) to the Department advising R1 returned to the facility from the Hospital on July 5, 2020 with a prohibited health condition. The facility received the hospital’s discharge documentation. The documentation from the hospital stated that a Home Health Agency (Nurse) contracted from the hospital would come clean and change the dressing for R1 wound. R1 was also prescribed medication for the condition. The facility Administrator Justice O Ehimamigho was trained then he trained his staff on the proper procedures to handle the prohibited health condition for R1.

SEE CONTINUATION FORM
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2020
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: STAINLESS RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 347005264
VISIT DATE: 07/28/2020
NARRATIVE
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On July 20, 2020, LPA Lund interviewed the Administrator Justice O Ehimamiegho and learned the local Hospital contacted the facility on July 5, 2020 and advised the R1 was ready for discharge. The Administrator did not conduct a re-appraisal (current condition) of R1 at the hospital, did not obtain an approved exception for the prohibited health condition, and did not have a written agreement with the home health agency regarding services, frequency or duration of care for the resident. R1 returned to the facility on July 5, 2020. On July 20, 2020, LPA Lund requested the above documentation and a request for an exception, however, the facility did not have the documents on file. It was also learned on this day, that R1 returned to the hospital for other ailments but would not return to the facility as the Administrator believed R1 needed a higher level of care.

Based on this investigation, the facility failed to obtain an exception, re-appraise R1 when conditions changed and failed to have a written home health agreement prior to retaining R1 with a prohibited health condition.

Deficiencies are cited from California Code of regulations, Title 22, Division 6, 8 and citations are listed on the attached LIC809D
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2020
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: STAINLESS RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 347005264
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/29/2020
Section Cited

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Prohibited Health Conditions:
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:
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This requirement is met evidence by:
Based on investigation, interview and review of incident report, the licensee did not have an exception prior to retaining a resident with a prohibited health condition. This poses an immediate health, safety, and personal rights risk to residents in care.
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Type A
07/29/2020
Section Cited

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Allowable Health Conditions and the Use of Home Health Agencies
Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met(4)The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident’s medical condition(s). (a)The written agreement shall reflect the services, frequency and duration of care. (b-c)...........
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This requirement is met evidence by:
Based on investigation and interview, the licensee did not have a Home Health care plan for caring for the resident’s medical condition. This poses an immediate 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: Stephenie DoubTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2020
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: STAINLESS RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 347005264
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/29/2020
Section Cited

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Reappraisals
The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: (3) Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) or 87615, Prohibited Health Conditions.
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This requirement is met evidence by:
Based on investigation and interviews, the licensee did not conduct a pre-appraisal of the resident to ensure they can care for the current medical needs of the resident. This poses an immediate 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: Stephenie DoubTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2020
LIC809 (FAS) - (06/04)
Page: 4 of 4