342700903-4-10-2025-27-AS-LRIS-DKYSJV-20250828135545

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700903
Report Date: 04/10/2025
Date Signed: 04/10/2025 04:40:49 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/22/2025 and conducted by Evaluator Renee Campbell

COMPLAINT CONTROL NUMBER: 27-AS-20250122145922

FACILITY NAME:	EHIMAS RESIDENTIAL CARE		FACILITY NUMBER:	342700903
ADMINISTRATOR:	STEPHANIE SIEWE		FACILITY TYPE:	740
ADDRESS:	407 MAPLE STREET		TELEPHONE:	(916) 912-8042
CITY:	GALT	STATE: CA	ZIP CODE:	95632
CAPACITY:	15	CENSUS: 14	DATE:	04/10/2025
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Stephanie Siewe, Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff inappropriately pushed a resident while in care

INVESTIGATION FINDINGS:

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On 04/12/2025, Licensing Programs Analyst (LPA) Renee Campbell arrived to the facility to present findings for a complaint. LPA Campbell was met by Administrator Siewe and explained the purpose of the visit.

On 01/30/2025, LPA Villanueva interviewed Staff 1 (S1). S1 stated R1 has a history of making up stories. S1 is not sure of which staff R1 was accusing of pushing R1. S1 stated R1 receives medications every month, and when it comes close to the monthly shot, R1 tends to start creating stories. S1 believes the pushing story might have happened when a staff was giving R1 support in the bathroom.

On 01/30/2025, LPA Villanueva interviewed Staff 2 (S2). S2 stated that R1 has a behavioral history of making up stories and making false accusations. S2 reported to LPA instances of when R1 previously stated false allegations against the facility staff. There was an incident where R1 accused facility staff that staff are not giving R1 their cough medication that R1's doctor prescribed. R1's nurse confirmed that R1 has no prescriptions for cough nor had been to ER for cough.

On 01/30/2025, LPA Villanueva attempted to contact the Reporting Party. However, a call back was not received. On 02/25/2025, LPA attempted to speak to the Reporting Party.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20250122145922

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: EHIMAS RESIDENTIAL CARE	FACILITY NUMBER: 342700903
	VISIT DATE: 04/10/2025

NARRATIVE

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LPA Valerio left a voicemail for a call back. A call back was not received.

On 02/25/25, LPA Valerio interviewed R1. R1 stated staff are nice sometimes. When asked to explain how staff treat R1. R1 explained but then expressed R1 was talking about another resident. R1 stated a staff pushed R1 while in the shower. LPA asked who the staff member was, which R1 identified. However, when LPA asked for R1 to clarify who the staff member was R1 could not identify the staff member a second time.

On 02/20/2025, LPA Valerio reviewed facility records. LPA Valerio reviewed an Unusual Incident Report dated 07/20/2024. The incident report involved R1. R1 reported that another resident killed 10 people. According to the licensee, the resident has been referred to R1 as R1's best friend and observed to be spending lots of time together. This incident occurred after R1 refused R1's monthly injection.

On 02/20/2025, LPA Valerio reviewed daily notes for R1 dated 2023 until current. LPA observed daily notes that discussed other incidents that occurred with R1 and staff; however none indicate that there was an incident that occurred in the shower.

Based on all the information collected by the Department, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED. California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of report was left at the facility.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025

LIC9099 (FAS) - (06/04)

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