<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700903
Report Date: 11/17/2022
Date Signed: 11/17/2022 02:22:22 PM

Document Has Been Signed on 11/17/2022 02:22 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: DATE:
11/17/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
06:00 AM
MET WITH:TIME COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/12022, Licensed Programming Analyst (LPA) Renee Campbell conducted an unannounced visit to this facility at approximately 6:18 am regarding multiple open complaints. LPA was greeted by the one staff present in the facility. .Stephanie. and stated the purpose of the visit. LPA observed staff preparing breakfast and assisting residents. Residents were interviewed by LPA regarding their care. Based on observations during facility visit on 11-17-22 and interviews with staff member and residents, facility was not sufficiently staffed to be able to provide adequate supervision of residents.

When 3 of 3 residents were interviewed, they agreed more staff were needed during NOC shift. Although staff stated on this visit that her partner had become ill during the NOC shift, residents stated there is usually only one staff available during the night or during breakfast before the day shift arrives. LPA observed staff attempting to prepare breakfast and care for 12 to 15 residents while making sure they did not fall or injure themselves. However one resident did comment on the improved state of the dining room walls. "It was wonderful."

LPA reviewed logs to review the staff who were present during the night shift. ............

i

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
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: EHIMAS RESIDENTIAL CARE
FACILITY NUMBER: 342700903
VISIT DATE: 11/17/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on record review of various incidents occurring between 8-21-22 to 11-16-22 it was determined that a total of 36 9-1-1 calls were made. Upon further review, it was determined that facility did not ensure incident reports were sent to the Licensing department for multiple incidents occurring during this time period. Of these 911 calls, on 9-15-22 a missing person report was made. In which the Galt Police department located the resident.

The following deficiencies are being cited during today's inspection per California Code of Regulations, Title 22.(LIC809-D)



An exit interview was conducted and a copy of the report was left at the facility.

,

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/17/2022 02:22 PM - It Cannot Be Edited


Created By: Renee Campbell On 11/17/2022 at 10:37 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: EHIMAS RESIDENTIAL CARE
FACILITY NUMBER: 342700903

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/19/2022
Section Cited
CCR
1569.312(d)

1
2
3
4
5
6
7
1569.312(d) - Basic Service Requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services:(d) Being aware of the resident's general whereabouts…This requirement was not met as evidenced by
1
2
3
4
5
6
7
LIcensee will increase engagement between staff and clients to modify behavior and update care plans to reflect the change in intervention. Licensee will provide updated care plans for impacted client by POC Due date.
8
9
10
11
12
13
14
Based on review of police documentation for a missing person report on 09/15/22.. This poses an immediate health and safety risk.
8
9
10
11
12
13
14
.
Type B
12/19/2022
Section Cited
CCR97411(a)

1
2
3
4
5
6
7
Personel Requirements - General: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...Additional staff shall be employed as necessary. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
 Licensee will conduct training and offer incentives regarding consistent staff attendance. Licensee will write and submit the training incentive to LPS by POC date date.
8
9
10
11
12
13
14
Based on observation and interviews, there was not sufficient staff available for nght shift to meet the needs and supervise the residents concurrently. This poses a potential health and safety risk.
8
9
10
11
12
13
14
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:Liza King
LICENSING EVALUATOR NAME:Renee Campbell
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 11/17/2022 02:22 PM - It Cannot Be Edited


Created By: Renee Campbell On 11/17/2022 at 10:56 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: EHIMAS RESIDENTIAL CARE
FACILITY NUMBER: 342700903

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/19/2022
Section Cited
CCR
87211(a)(D)

1
2
3
4
5
6
7
Reporting Requirements. (a) Each licensee shall furnish to the licensing agency...(1) A written report shall be submitted to the licensing agency...within seven days of the occurrence...(D)Any incident which threatens the welfare, safety or health of any resident...The requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee will require staff to confirm if 911 was called during their shift and if an incident report was submitted. Licensee will provide a copy of the dailly confirmation sign in sheet for two weeks as of the POC date.
8
9
10
11
12
13
14
Based on record review and interview, licensee did not ensure reports were sent to licensing agency for multiple incidents occurring between 8-21-22 to 11-16-22 when there were 36 911 calls. This poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
Type B
12/19/2022
Section Cited
CCR1569.50(a)(3)

1
2
3
4
5
6
7
(3) Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California.. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee will read and review and educate and train staff regarding regulations and their impact on the facility. To provide proof, licensee will provide documentation of a training plan and submit a statement of understanding of 1569.50(a)(3) and 87211(a)(D).
8
9
10
11
12
13
14
Based on record review, licensee did not ensure that reporting requirements were met with adequate supervision for the health and safety of residents in care based on 911 call logs obtained.
8
9
10
11
12
13
14
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:Liza King
LICENSING EVALUATOR NAME:Renee Campbell
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022


LIC809 (FAS) - (06/04)
Page: 4 of 4