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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623100
Report Date: 09/12/2024
Date Signed: 09/12/2024 11:15:51 AM

Document Has Been Signed on 09/12/2024 11:15 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:EKEKWE, ELSHEBIAFACILITY NUMBER:
343623100
ADMINISTRATOR/
DIRECTOR:		EKEKWE, ELSHEBIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 517-8410
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 6DATE:
09/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Elshebia EkekweTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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On 09/12/2024 at approximately 9:15 AM Licensing Program Analysts (LPAs) Loraine Perez and Lea Habtom met with Licensee Elshebia Ekekwe, for an unannounced case management incident inspection regarding an injury that occurred on June 6th, 2024. The reason for the inspection was explained to the Licensee.  There is a census of 6 children in care. Present in the home is the Licensee.  All individuals subject to criminal background review have obtained a criminal record clearance. Facilities hours of operation are Monday through Friday 7:30 AM to 4:30 PM.

An interview with the licensee revealed that on June, 26, 2024, a child was injured and was taken to seek medical treatment by parent. Based on the interview, this injury was not called in to the department within 24 hours and reported within 7 days on the LIC 624. 

In the areas that were evaluated, deficiency was observed at the time of the visit and cited on LIC 809D. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Licensee Elshebia Ekekwe. Appeal rights were provided
SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Loraine Perez
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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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Document Has Been Signed on 09/12/2024 11:15 AM - It Cannot Be Edited


Created By: Loraine Perez On 09/12/2024 at 09:51 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: EKEKWE, ELSHEBIA
FACILITY NUMBER: 343623100

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/13/2024
Section Cited
CCR
102416.2(b)(1)

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The licensee shall report to the Department any of the events as specified in Health and Safety Code Sections 1597.467(b)(1)(A) through (b)(1)(C) that occur during the operation of the family child care home. Medical treatment... medical professional, as defined in Section 101152(m).


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LPA reviewed reporting requirements timeframes and provided licensee with the LIC 624 & the regulation information. Licensee acknowledged and is aware of reporting requirements.
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This requirement was not met as evidenced by:

Based on interview with Licensee, the licensee did not report to the department an injury that occurred at the facility that later required medical treatment.
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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:Amanda Blesi
LICENSING EVALUATOR NAME:Loraine Perez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024


LIC809 (FAS) - (06/04)
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