Ehimas Residential Care

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Christina Valerio arrived to the facility to conduct a quarterly case management visit. LPA met with Administrator Justice Ehimamiegho, and explained the purpose of the visit. Based on the Non Compliance Conference (NCC) on 4/12/23 the following areas will be assessed: · The Administrator is present for a minimum of 40 hours a week - Based on records review, LPA Valerio determined that the Administrator is present for a minimum of 40 hours per week. LPA received notification that facility staff Stephanie received her administrator certificate. LPA observed documents and clarified that the correct documentation has been completed and he needs to send to LPA via email/fax. · The licensee has not accepted any residents determined by a physician to have a primary diagnosis of a mental disorder unrelated to dementia - LPA observed one resident to be admitted after 08/2023. The resident did not have a primary diagnosis of a mental health disorder unrelated to dementia. · The licensee ensured that they are in compliance with the state Fire Marshall; The facility has a non ambulatory fire clearance for each room that will be used to accommodate a resident with dementia - LPA confirmed that they are within compliance. · Meals were observed during the visit. LPA did not observe meal time; however, LPA observed a left over plate, which had pasta shells with sauce, vegetables and ground meat and a half turkey sandwich. LPA conducted observations of the meal prep area, freezer, refrigerator were conducted. LPA observed the meal prep area to have a resident's plate with name since the person did not eat yet. LPA observed the freezer and refrigerator to be fully stocked and clean from debris or spoiled food. TA was provided on a separate 809 for an emergency supply of food. Per California Code of Regulations (CCR) - Title 22, no deficiencies are being cited today. An exit interview was held, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 2, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual required inspection. LPA attempted to open the LIC 809 as an annual required visit, however, due to technical difficulties, LPA had to open the LIC 809 as a case management - annual continuation. LPA was met by facility staff Stephanie Siewe, and explained the purpose of the visit. LPA was then met by Administrator (ADM) Justice. ADM and LPA Valerio toured the facility to ensure compliance with Title 22 regulations. LPA observed resident bedrooms to be equipped with a bed, night stand, closet space, a dresser, and lights. Common areas were observed to have necessary furniture and did not appear to be malodorous. LPA measured the hot water in 2 bathrooms, which was measured to be within the regulatory range of 105.0*F - 120.0*F. LPA observed the kitchen; knives were locked and inaccessible to residents in care. Lunch today was pasta shells with sauce, vegetables and ground meat and a half turkey sandwich. LPA observed 4 staff files, which had the required first aid/CPR training. LPA observed 3 resident files, which was observed to have all necessary files with current information and updated for year 2023. Residents were observed taking a nap, watching television, being assisted by a staff, and sitting in the backyard. LPA spoke to multiple residents during the visit. Technical Advisory was provided for the sink and shower for the bathroom located towards the back of the home. According to administrator, he had previously tried to fix the sink but believes the whole sink needs to be replaced. Administrator stated that they plan to replace the entire walk-in shower. Technical Advisory was provided for an emergency supply of food and water. Administrator stated he will obtain the emergency supply food/water from a wholesale store by COB. An exit interview was held, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 2, 2023

Allegation investigated: Financial issues: Owner is forcefully requesting financial bank information

Sacramento South Regional Office held an office meeting via Microsoft teams on 10/25/23 at 11:00 AM. The purpose of the meeting was to discuss Solvency and Trust Audit Report Findings. Present in today's meeting were Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Maja Jensen, LPA Christina Valerio, Gereral Auditor (GM) Jorge Mojica, and Licensee/Administrator Justice Ehimaiegho. Based on interviews conducted with facility staff, residents, and family/payee/conservator -there is no evidence facility staff misappropriated resident's monies or that they applied undue influence on residents (for financial gain) therefore the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. No citations are being issued as a result of the investigation in to this allegation. A copy of this report and appeal rights were provided to the Licensee. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 25, 2023 · control 27-AS-20230313102459

Allegation investigated: Facility staff forged client's check for personal gain

Sacramento South Regional Office held an office meeting via Microsoft teams on 10/25/23 at 11:00 AM. The purpose of the meeting was to discuss Solvency and Trust Audit Report Findings. Present in today's meeting were Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Maja Jensen, LPA Christina Valerio, Gereral Auditor (GM) Jorge Mojica, and Licensee/Administrator Justice Ehimaiegho. Based on interviews conducted with facility staff, residents, and family/payee/conservator -there is no evidence facility staff misappropriated resident's monies or that they applied undue influence on residents (for financial gain) therefore the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. No citations are being issued as a result of the investigation in to this allegation. A copy of this report and appeal rights were provided to the Licensee. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 25, 2023 · control 27-AS-20230306143246

Type of visit: Office

Sacramento South Regional Office held an office meeting via Microsoft teams on 10/25/23 at 11:00 AM. The purpose of the meeting was to discuss Solvency and Trust Audit Report Findings. Present in today's meeting were Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Maja Jensen, LPA Christina Valerio, Gereral Auditor (GM) Jorge Mojica, and Licensee/Administrator Justice Ehimaiegho. Topics of Discussion: Solvency Audit Report Findings - Based on information received and reviewed, it appears licensee has not established or maintained a financial plan Operating Income: Facility’s operations generated a net profit, during the sampled month. However, reported food costs were below USDA guidelines and must be increased. Reported Food Cost is $2,800 and USDA suggested Food Cost for 14 Residents is $3,437.00. Cash Reserves: Licensee does not maintain sufficient cash reserves to ensure provision of care and supervision to residents. Recommended amount is to equal the monthly operating cost. Trust Audit Report Findings - Improvement is needed in licensee's procedures when handling and safeguarding of resident monies. Staff is handling resident’s monies but did not notify regional office or obtain a Surety Bond. Licensee safeguards some residents’ debit cards but did not notify the regional office or obtain requisite Surety Bond. In addition, affected persons did not know (or did not recall) that facility staff safeguarded their debit cards. Licensee should make reasonable efforts to safeguard resident property, including implementing a theft and loss program. Continues on LIC 809 - C... Continued from LIC 809 2. Trust Audit Report Findings Continued - Licensee did not provided requested items to auditor, even after multiple requests. Licensee will do the following: Licensee to provide to Audits Section by January 22, 2024: A balance sheet (LIC 403 or equivalent) reflecting all assets and liabilities, as of December 31,2023, an income statement (LIC 401 or equivalent) for the months of October 2023, November 2023, and December 2023 summarizing all income and expenses, and month end bank statements for all operating and savings accounts used for licensed facility for period of October 1, 2023, thru December 31, 2023. Other information and documentation to be requested, as needed. Licensee to provide to Audits Section by the 3rd week following each quarterly visit, provide to Audits Section an, income statement (LIC 401 or equivalent) with support, for the last month in the quarter and Bank statements (savings and checking accounts) and Utility vendor’s billings for each month of the previous quarter. Licensee to provide the Regional Office a statement regarding Licensee Business Cash Reserves by November 27th, 2023 Licensee to submit a statement whether they will or will not change their plan of operation regarding handling/safeguarding resident monies by November 11th, 2023 Licensee to submit a copy of in-service training provided to staff regarding Bonding, Safeguard for Resident Cash, Personal Property, and Valuables, and Theft and Loss by November 11th, 2023 The Regional Office will do the following: Continue Quarterly Financial Monitoring for a period of 1 year (to October 31, 2024) RO to determine quarterly status after two quarterly periods Continue to collaborate with Licensee as needed Per California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, deficiencies are being cited on today's visit. Technical Advisory was provided for Title 22, Section 8755, General Food Service Requirements. An exit interview was held, and a copy of the report was provided via e-mail. Licensee to review, sign, and return signed copy to LPA by COB 10/272023.the state’s words, verbatim · CDSS document, Oct 25, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87213 · Plan of correction due date: Nov 27, 2023

87213 Finances The licensee shall have a financial plan that conforms to the requirements of Section 87155... and that assures sufficient resources to meet operating costs for care of residents... This requirement was not met as evidenced by: Based on audit report findings, the licensee did not maintain sufficient cash reserves to ensure providision of care and supervision to residents in care.the state’s words, verbatim · CDSS document, Oct 25, 2023

Plan of correction: Licensee stated he will submit a financial plan to ensure facilty reserves can be increased to the required amount. Financial Plan shall be submitted by POC due date

From the deficiency page — Deficiency type: Type B · Section cited: CCR87216(a) · Plan of correction due date: Nov 3, 2023

87216 Bonding(a) Each licensee, other than a county, who is entrusted to safeguard resident cash resources, shall file or have on file with the licensing agency a copy of a bond issued by a surety company to the State of California as principal... This requirement was not met as evidenced by: Based on audit report findings, the licensee did not ensure 3 residents' monies were not handled by staff and when done so licensee did not obtain Surety Bond, which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 25, 2023

Plan of correction: Licensee stated training will be provided to administrator and staff regarding not handling residents' monies. Licensee to send proof of training by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(a) · Plan of correction due date: Nov 3, 2023

87217 Safeguards for Resident Cash, Personal Property, and Valuables (a)...if a resident incapable of handling his own cash resources...cash resource shall be safeguarded in accordance with the regulations in this section. This requirement was not met as evidenced by: Based on audit findings, the licensee did not ensure to make reasonable efforts to safeguard resident property, which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 25, 2023

Plan of correction: Licensee stated training will be provided to administrator and staff regarding Safeguards for Resident Cash, Personal Property, and Valuables. Proof of training will be provided by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87218(a) · Plan of correction due date: Nov 3, 2023

87218 Theft and Loss (a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153. This requirement was not met as evidenced by: Based on audit report findings, the licensee did not ensure to have a theft and loss program in plan, which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 25, 2023

Plan of correction: Licensee stated training will be provided to administrator and staff regarding the facility's Theft and Loss Program. Proof of training will be provided by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(b) · Plan of correction due date: Nov 3, 2023

87405 Administrator - Qualifications and Duties (b) The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee. This requirement was not met as evidenced by: Based on audit report findings, the licensee did not ensure administrator followed their policies of the facility, which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 25, 2023

Plan of correction: Licensee stated administrator will complete required training, continue to collaborate with the Regional Office, and submit all necessary documentation to audits and the RO by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87755(b) · Plan of correction due date: Nov 3, 2023

87755 Inspection Authority of the Licensing Agency (b) The licensee shall ensure that provisions are made for private interviews with any resident or any staff member; and for the examination of all records relating to the operation of the facility. This requirement was not met as evidenced by: Based on audit report findings, the licensee did not respond to Auditor's request for documentation, which poses a potential health, safety, and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Oct 25, 2023

Plan of correction: Licensee stated administrator missed the e-mails and apologized for the oversight. Licensee to review regulations 87755 and submit a statement acknowledging understanding. Statement due to the RO by POC due date.

Type of visit: Case Management - Health Checks

On 9/14/23 at approximately 1:40 pm Licensing Program Analyst Jennifer Fain and Licensing Program Manager Liza King arrived at the facility to conduct a follow up Legal Noncomplaince Case Management Visit from 8/25/23. LPA and LPM met with Stephanie Siewe and explained the reason for the visit. On 8/30/23 LPA Fain received requested documents: 602s for all residents and the facility sketch. During the Informal Meeting on 4/12/23 the licensee agreed to “evaluate the current STD850 to ensure that they are in compliance with the state Fire Marshall; The facility has a non-ambulatory fire clearance for each room that will be used to accommodate a resident with dementia within 2 days; submit an updated LIC200 and facility sketch.” Based on the 602’s supplied for the residents, the facility sketch, and rooms the residents are staying in (provided by S1 on 8/25/23), there are 8 non-ambulatory residents, 4 of them are in ambulatory rooms. Also, during the Informal meeting, the Licensee agreed to “Conduct a self-assessment of all resident and personnel files within 30 days and make needed updates per requirements.” Based on the 602’s received 4 of 6 are past the due date for the required one year health evaluation. LPA requested Discharge papers for R1 from hospital visit on 8/5/23 and related SIR. LPA requested Incident Reports and discharge papers for R2 for the months of June, July and August 2023. A civil penalty of $500 is being issued during today's visit for violation of California Code of Regulations Title 22 Section 87204(b). The facility is not in compliance with Title 22 Regulations, the deficiencies can be found on the LIC 809-D page. An exit interview was conducted with Stephanie Siewe, and a copy of this report and appeal rights were provided to Stephanie Siewe.the state’s words, verbatim · CDSS document, Sep 14, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705 · Plan of correction due date: Sep 15, 2023

Care of Persons with Dementia (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by: Based on record review of the 602s provided, the licensee did not ensure residents’ health records were up to date which poses a potential Health, Safety, and Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 14, 2023

Plan of correction: Administrator will email a plan of correction by 9/15/23 to jennifer.fain@dss.ca.gov

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87204 · Plan of correction due date: Sep 15, 2023

Limitations - Capacity and Ambulatory Status (b) Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nonambulatory shall not remain in rooms restricted to ambulatory residents. This requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee did not ensure nonambulatory residents were housed in nonambulatory rooms which poses an immediate Health, Safety, and Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 14, 2023

Plan of correction: Administrator will email a plan of correction by 9/15/23 to jennifer.fain@dss.ca.gov

Type of visit: Office

A Noncompliance Conference (NCC) was conducted today, via Microsoft Teams. The purpose of the NCC was to discuss the facilities substantiated complaint of a violation of personal rights. Present at today’s NCC were the Regional Office Manager Stephenie Doub, Licensing Program Manager (LPM) Liza King, Licensing Program Analysts (LPAs) Jennifer Fain and Maja Jensen, Karen Hicks Telecare Case Manager, and Licensee, Justice Ehimamiegho. The administrative process was explained during this meeting and Licensee was informed that further citations may result in Administrative Action. The following issues were discussed during the conference: · Assessment · Appraisal and Reappraisal · Incidental Medical care · A substantiated complaint of a violation of personal rights. Licensees stated they will do the following to achieve continued and substantial compliance: · Ensure the use of emergency and nonemergency transportation as necessary to meet the needs of the residents in care · Ensure Administrator presence for a minimum of 40 hours a week · Maintain all resident and personal files per requirements. Additional information provided by the licensee during the meeting included: process for assessments, process for monthly file review, plan for incontinence care, day and evening schedule for client checks, Continued on 809 C In addition, as discussed during the Informal conference, the following will continue to be monitored: · The licensee will refrain from accepting or retaining residents determined by a physician to have a primary diagnosis of a mental disorder unrelated to dementia. · Utilize an offsite training for Mandated Reporting and de-escalation within 30 days of the informal date · Engage the residents in the menu process within 30 days and document preferences. · Review and amend the current incontinence plan to be approved by the Department within 90 days. The Regional Office has agreed to continue increased monitoring. TSP has been provided, and additional training have been requested of TSP to include · Reporting Requirement training of all staff Assessment and Reassessment Training of all staffthe state’s words, verbatim · CDSS document, Aug 29, 2023

Allegation investigated: Facility staff are not adequately supervising resident while in care.

On 8/28/25 at approximately 3:45pm Licensing Program Analysts (LPAs) Jennifer Fain and Maja Jensen arrived at facility unannounced to deliver findings for a complaint investigation related to the above listed allegation. LPAs met with Facility Manager Stephenie Siewe and explained the purpose of today's visit. LPA Fain reviewed Galt Police Department incident report #2305190056, dated 5/19/23, which states that an unknown female entered a residence without permission. The responding officer located resident 1 (R1) near the residence. The officer was familiar with R1 from previous contacts. The responding Officer returned R1 to the care home and into Staff 1’s (S1) care. R1 has a history of elopement. Review of the Physician’s report for R1 states the resident may leave the facility unaccompanied. On 7/18/23 Licensee reported he had begun the process of updating the Physician’s Report and having R1 conserved. LPA was unable to interview R1 as resident was hospitalized and had not returned to the facility. Continued on LIC 9099C... Substantiated Continued from LIC 9099.... Based on Galt Police Department incident report #2305190056, R1 Physician’s report, prior Case Managements at this facility and Incident reports faxed to Community Care Licensing, as well as interviews with the Administrator and Staff 1, the allegation of Facility staff are not adequately supervising resident while in care is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met. Deficiencies are being cited from California Code of Regulations Title 22, Division 6. Failure to correct deficiencies may result in additional civil penalties and administrative action. An exit interview was conducted, and a copy of this report, an LIC 811 and appeal rights were given to Stephanie Siewe.the state’s words, verbatim · CDSS document, Aug 25, 2023 · control 27-AS-20230530132443

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Aug 25, 2023

(a) … residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by:Based on interviews conducted and records reviewed, and the resident’s return by police officer, the licensee did not ensure the resident’s supervision needs were met, which poses an immediate Health, Safety and Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 25, 2023

Plan of correction: The Licensee agrees to write an attestation stating the above regulation has been read understood and will be complied with. Resident needs a higher level of care and has moved to another facility.

Allegation investigated: Staff did not properly groom a resident while in care

On 8/25/23 at approximately 2pm, Licensing Program Analysts (LPAs) Maja Jensen and Jennifer Fain arrived at facility unannounced to continue an investigation in to the above listed allegation. LPA Jensen met with facility manager Stephanie Siewe and explained the purpose of today's visit. During the course of the investigation LPA Jensen interviewed 2 staff members, 7 of 12 residents and 1 responsible party for a resident. 2 of 2 staff advised that the facility has a standard morning routine for grooming the residents that includes assistance with brushing teeth, washing face and brushing hair if needed. Many clients can do some of these activities themselves. The facility manager stated that showers are given on an as needed basis and every client is different. Some clients require daily showers, some receive showers every other day and some twice a week. The care provider interviewed stated each client is showered at least twice a week. Continued on LIC 9099C.... Unsubstantiated The staff manager also explained that some clients choose to wear clothing inappropriate for the weather or season and when this occurs staff tries to encourage the resident to change clothing. 6 of 7 clients interviewed stated they have no concerns regarding grooming and that services provided are adequate. LPA Jensen observed signs on resident bedroom doors specifying the shower schedule for the occupants of that room. Based on the interviews conducted with staff and residents as well as postings observed on resident doors the allegation of staff did not properly groom a resident while in care is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. No citations are being issued. An exit interview was conducted and a copy of this report, appeal rights and LIC 811 were given.the state’s words, verbatim · CDSS document, Aug 25, 2023 · control 27-AS-20230227143013

Type of visit: Case Management - Other

On 8/25/23 at approximately 2pm Licensing Program Analysts (LPAs) Jennifer Fain and Maja Jensen arrived unannounced to collect documents for a comprehensive quarterly visit. LPAs met with Stephanie Siewe and explained the reason for the visit. On arrival residents were observed in the living room watching tv, congregating in the hallway and resting in their rooms. The kitchen was observed to be sanitary. Dinner was prepped for tacos. Based on the Non Compliance Conference on 4/12/23 the following areas will be assessed: · The Administrator is present for a minimum of 40 hours a week *** August schedule requested and received. · The licensee has not accepted any residents determined by a physician to have a primary diagnosis of a mental disorder unrelated to dementia *** Physicians' reports for residents admitted after 4/12/23 requested and received. · The licensee ensured that they are in compliance with the state Fire Marshall; The facility has a non ambulatory fire clearance for each room that will be used to accommodate a resident with dementia *** 602s requested for all residents. Facility will email by Wednesday, 8/30/23. · Meals were not observed during the visit. LPA Fain will return after all documents are received and reviewed for the Quarterly Health and Safety Check. No Deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report was provided to Licensee.the state’s words, verbatim · CDSS document, Aug 25, 2023

Type of visit: Office

An office meeting was held today via Microsoft Teams with the Sacramento South Regional Office. The purpose of this meeting was to discuss the Technical Support Program Engagement Summary (TSP) generated on 7/28/2023. Present at this meeting were Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Jennifer Fain, Heidi Allen- Intensive Placement Team for Sacramento County & CCLD Liaison, and representing Ehimas was Licensee Justice Ehimasmiegho. LPM and LPA discussed the following topics previously addressed at the TSP Engagement: · Care and Supervision · Personnel/ Training · Food Services Licensee reported that they have implemented the following as a result of TSP involvement: · Staff meetings and staff training occur once a month on the second and last Sundays, respectively. · Trainings have been completed, including but not limited to: Safe Serve, Fall Prevention, and Mandated Reporting · Resident Council meetings were attempted, especially to discuss the menu, but there was little resident interest Licensee requests assistance with SIR training. LPM King will coordinate with TSP. LPA Fain will send link to Training Requirements PIN to Licensee. The RO will continue to conduct quarterly monitoring and provide any TA needed. No citations were issued today. An exit interview was conducted with Justice Ehimamiegho and a copy of this report was emailed to Justice with a request to return with signature to Jennifer.fain@dss.ca.gov.the state’s words, verbatim · CDSS document, Aug 23, 2023

Allegation investigated: Staff neglect resulted in a resident sustaining multiple injuries while in care

On 8/17/23, Licensing Program Analyst, (LPA) Maja Jensen arrived at facility unannounced to deliver findings in the complaint investigation related to the above listed allegation. LPA Jensen met with Justice Ehimamiegho and explained the purpose of today's visit. During the course of the investigation the Department reviewed the Resident File for resident 1 (R1), the facility's daily note logs, medical records and pre-hospital care report. The Department also conducted interviews with R1, R1's family members, R1's case Telecare case worker, facility staff, facility residents and medical doctors involved in the R1's care. On 02/23/2023, Resident 1 (R1) suffered a fall. As a result of the fall, R1 was transported to the Emergency Room. R1 was assessed and was diagnosed with chronic rib fractures on his left and right side and two chronic transverse process fractures (spine). Continued on LIC 9099C... Substantiated Continued from LIC 9099.... The Doctor of Medicine (M.D. ) who reviewed R1’s computed tomography (CT) scan indicated that he could not definitively say when the injuries occurred or if they were a result of the same or different incidents. The M.D. stated that the fractures could have been a month to multiple months old and that they could have occurred at the same time or at different times. The M.D. stated that the cause of the fractures could have been falls, accidents, or direct blows. R1 moved into the facility in September of 2022. Staff reported that R1 was a fall risk and that he fell frequently. Records from the facility document that R1 fell on 11/19/2022, 11/29/2022, 12/16/2023, 12/24/2023, and 02/23/2023. Paramedics assessed R1 after the fall on 12/16/2023, but R1 was not taken to the hospital. Consumnes Fire Department Report #F202220234263 documents that facility staff (S1) signed the Patient Care Report and acknowledged refusal of transport. R1 was not assessed at the hospital until after the fall on 02/23/2023. According to facility staff and records, R1’s care plan was never updated after he suffered any of his falls. Facility staff indicated that R1 was a fall risk beginning on the date of his admission. Fall prevention measures included reminding R1 to use his wheelchair or walker as well as providing extra visual supervision of him. Facility staff did not implement any other preventative actions to ensure that R1 did not suffer further falls. Based on records reviewed and interviews conducted the allegation of Staff neglect resulted in a resident sustaining multiple injuries while in care is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met. As a result of this investigation, deficiencies are being cited from the California Code of Regulations, Title 22, Division 6 and a civil penalty for a repeat violation is being assessed. At the time of the complaint visit, the issuance of an additional Civil Penalty was still being determined and the licensee was informed that a civil penalty may be assessed based on Health and Safety Code § 1569.49. An exit interview was conducted and a copy of this report, appeal rights and confidential names list was provided.the state’s words, verbatim · CDSS document, Aug 17, 2023 · control 27-AS-20230227143013

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Aug 18, 2023

Additional Personal Rights of Residents in Privately Operated Facilities ...residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: ...To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Based on records reviewed and interviews conducted staff did not adequately supervise R1 resulting in multiple falls with serious bodily injury. This poses an immediate risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Aug 17, 2023

Plan of correction: The Licensee agrees to email an attestation to LPA at maja.jensen@dss.ca.gov that the regulation has been read, understood, and will be compiled with by the POC due date.

Type of visit: Case Management - Deficiencies

On 8/17/23, Licensing Program Analyst, (LPA) Maja Jensen arrived at facility unannounced to conduct a case management for deficiencies. LPA Jensen met with Justice Ehimamiegho and explained the purpose of today's visit. The Department conducted an investigation in relation to complaint control # 27-AS-20230227143013. During the course of that investigation and based on facility records it was determined Resident 1 (R1) fell on 11/19/2022, 11/29/2022, 12/16/2023, 12/24/2023, and 02/23/2023. Paramedics assessed R1 after the fall on 12/16/2023, but R1 was not taken to the hospital. Consumnes Fire Department Report #F202220234263 documents that facility staff S1 signed the Patient Care Report and acknowledged refusal of transport. S1 reported that the paramedics refused to transport Gregory to the hospital and that she was not the one to make the decision to not send R1 to the hospital however the Consumnes Fore Department Pre hospital Care Report states " staff signed against medical advice and witnessed via crew. No further patient care provided and crew cleared scene" R1 was not assessed at the hospital until after the fall on 02/23/2023. The resident's needs and service plan is dated 12/9/22 and was not updated after the fall from 12/16/23 or 12/24/23 despite the fact that fall prevention measures that the Administrator claims were in place were ineffective. Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of Civil Penalties. An exit interview was conducted and a copy of this report, a confidential names list and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 17, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Aug 18, 2023

Incidental Medical and Care ...The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not as evidenced by: Based on the Consumnes Fire Department, Prehospital Care Report #F22234263, S1 signed an order for R1 not to be transported to the Emergency Department against medical advice. This poses an immediate risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Aug 17, 2023

Plan of correction: The Licensee agrees to send a signed attestation that this regulation has been read, understood and will be complied with to maja.jensen@dss.ca.gov by bPOC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87463(a) · Plan of correction due date: Aug 17, 2023

Reappraisals The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. This requirement was not met as evidenced by: Based on records reviewed the resident appraisal was not updated after R1 sustained multiple signficant falls. This poses an immediate risk to health safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Aug 17, 2023

Plan of correction: The Licensee agrees to send a signed attestation that this regulation has been read, understood and will be complied with to maja.jensen@dss.ca.gov by bPOC due date.

Type of visit: Case Management - Other

On 7/19/23 at approximately 9am Licensing Program Analyst (LPA) Maja Jensen and a department auditor arrived at facility for a scheduled visit to continue collecting data for a trust audit. LPA Jensen and the Department auditor met with Licensee Justice Ehimamiegho and Stephanie Siewe and explained the purpose of today's visit. During the course of the visit the department auditor interviewed 7 of 12 residents. In addition the auditor scanned copies of the LIC 602 and admission agreement for residents 1 through 7 (R1-R7). An exit interview was conducted and a copy of this report was handed to Stephanie Siewe.the state’s words, verbatim · CDSS document, Jul 19, 2023

Allegation investigated: Staff is withholding resident's medications

At approximately 10am on July 18, 2023 Licensing Program Analysts Maja Jensen and Jennifer Fain arrived at facility unannounced to continue a complaint investigation in to the above listed allegation. LPA Jensen met with Licensee Justice Ehimamiegho and explained the purpose of today's visit. During the course of an interview with the Licensee, LPA Jensen was advised that medication is not witheld but rather the resident always requests medication early and the facility only administers medication a maximum of 1 hour early. During the course of a previous site visit made for the purposes of investigating the 14 allegations on this complaint, S1 complained to LPA Jensen that his medications were being withheld and he is in so much pain he can barely walk. It should be noted that S1 uses a walker. LPA Jensen checked theMedication Administration Record (MAR) and advised S1 that he still has 2 hours to go before his next dose but that the facility was willing to give him his medication an hour earlyContinued on LIC 9099C... Continued on LIC 9099C.... Unsubstantiated S1 stated he cannot wait that long because he is pain and LPA Jensen asked him if he wants to go to the emergency room given that he is experiencing such a high level of pain. S1 stated he did not want to go to emergency room because it is too much waiting around. S1 then picked up his walker and walked to his room carrying his walker without incident. While the Department was investigating other allegations related to S1 it was discovered that S1 has a history of making false allegations. Based on LPA Jensen's review of the MAR, interview with the Licensee and LPA Jensen's direct interaction with S1 regarding the allegation, the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. No citations are being issued as a result of the investigation in to this allegation. A copy of this report and appeal rights were handed to the Licensee. Continued from LIC 9099... Deficiencies are being cited from the California Code of Regulations (CCR). Failure to correct deficiencies may result in the assessment of civil penalties. An exit interview was conducted and a copy of this report and appeal rights were handed to Administrator Justice Ehimamiegho.the state’s words, verbatim · CDSS document, Jul 18, 2023 · control 27-AS-20230303123659

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jul 19, 2023

Additional Personal Rights of Residents in Privately Operated Facilities ...residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:... To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Based on LPA Jensen's and Fain's observations of residents during the course of a site visit on 3/20/23 as described in the LIC 9099A. This poses an potential risk to the health, safety and personal rights of residents in carethe state’s words, verbatim · CDSS document, Jul 18, 2023

Plan of correction: The Licensee has hired a 1:1 staff member for R1 as of May 2023. In addition the Licensee has reduced capacity in an effort to increase the quality of care. The Licensee also agrees to supervise residents during meal service effective immediately. Licensee will email an attestation to maja.jensen@dss.ca.gov regarding supervision of meal service by 7/19/23.

Type of visit: Case Management - Other

On 6/18/23 at approximately 11:00am LPA Jennifer Fain met LPA Maja Jenson at the residence unannounced to continue a complaint investigation. LPAs met with Stephanie Siewe and explained the purpose of the visit. LPA Fain requested and received copies of the May and June employee schedule. LPA Fain requested payroll records from May 2023 and June 2023 be emailed to Jennifer Fain at jennifer-fain@dss.ca.gov by Friday, July 28, 2023. This investigation will take additional time to complete. An exit interview was conducted with Stephanie Siewe and a copy of this report was given.the state’s words, verbatim · CDSS document, Jul 18, 2023

Type of visit: Case Management - Other

On 7/18 at approximately 1pm Licensing Program Analysts (LPAs) Maja Jensen, Jennifer Fain and a department auditor arrived at the facility to conduct a solvency and trust audit entrance conference. LPAs Jensen and Fain and the auditor met with Licensee Justice Ehimamiegho and his accountant and explained the purpose of the visit. The auditor advised the Licensee of the allegations that triggered the audit. The Licensee's accountant spoke to the auditor on 7/14/23 and requested an extension to provide documents for the solvency audit which was granted through 7/20/23. The auditor and LPA Jensen reviewed the contents of a facility safe with the Licensee and reviewed 9 of 12 resident files. Due to time constraints this audit will be continued tomorrow, 7/19/23. An exit interview was conducted and a copy of this report was handed to Licensee Justice Ehimamiegho.the state’s words, verbatim · CDSS document, Jul 18, 2023

Allegation investigated: Resident fell and sustained multiple injuries Staff did not seek timely medical attention for resident

.Licensing Program Analyst (LPA) Maja Jensen arrived at facility for a complaint investigation in to the above listed allegations. LPA Jensen met with Justice Ehimamiegho and explained the purpose of today's visit. With respect to the allegation of resident fell and sustained multiple injuries due to neglect or a lack of care and supervision, staff were interviewed, clients were interviewed, Incident Reports reviewed, and medical records reviewed. It was determined that there was an unwitnessed fall on 2/26/2023, but Resident 1 was being appropriately supervised according to his care plan which does not state he needs checks at all. Staff were interviewed and disclosed they checked on Resident 1 twice between 1300 and 1600 hours on the date in question. At around 1630 hours, Resident 1 was found in his bed with bruising on his face and was sent to the hospital. Based on the interviews conducted and the records reviewed this allegation is UNFOUNDED. A finding of unfounded means the allegation is false, could not have happened or is without a reasonable basis. Unfounded Continued from LIC 9099... With respect to the allegation of staff did not seek timely medical attention for resident, staff were interviewed, clients were interviewed. In addition, Incident Reports were reviewed, and medical records were reviewed. It was determined that R1 had an unwitnessed fall 2/26/2026 but was being treated appropriately according to his care plan. Upon discovering R1's injuries, staff called paramedics and sent R1 to the hospital on 2/26/2023, minutes after discovering his injuries. Incident reports and medical records support the chronology of events therefore the allegation of staff did not seek timely medical attention for resident is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened, or is without a reasonable basis. An exit interview was conducted and a copy of this report and appeal rights were provided. Continued from LIC 9099A... The other clients who alleged the assault, got their information about the assault from R6. Their accounts were inconsistent, and none of the clients witnessed the incident themselves. The victim, R1, suffers from Dementia and does not recall the assault or the fall. Medical records were reviewed. R1 was seen on 2/26/2023 for the unwitnessed fall, and on 3/2/2023 after reports of being assaulted were made. According to the medical records there were no new injuries on 3/2/23 and no evidence to support he had been assaulted. As a result of the interviews conducted and the records reviewed the allegation of due to lack of staff supervision, resident had a physical altercation with another resident resulting in injury is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. LPA Jensen interviewed staff members, interviewed clients, reviewed law enforcement incident reports and facility records. It was determined that on multiple occasions residents have left the facility unassisted however there was no evidence found to support that residents left without staff knowledge. The facility maintains a sign out log for residents which does contain entries of residents leaving over the course of the last 3 months. The facility also maintains a log of notes regarding any unusual incidents and there were no entries observed for the year of 2023 that would indicate an elopement without staff knowledge. Based on the interviews conducted and the records reviewed the allegation of resident eloped without staff knowledge is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. LPA Jensen observed food preparation on 5/25/23, 4/28/23 and 3/20/23. LPA Jensen confirmed with site supervisor Stephanie Siewe that all staff completed ServSafe training in April and May. At this time all kitchen appliances are in good working order. There was no evidence of pest infestation observed. LPA Jensen asked kitchen staff to show LPA the cleaning supplies used for the kitchen and demonstrate cleaning protocol which was determined to be adequate. Based on observations made over the course of multiple visits the allegation of food is not prepared in a sanitary manor is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it. An exit interview was conducted and a copy of this report and appeal rights were given.the state’s words, verbatim · CDSS document, May 25, 2023 · control 27-AS-20230303123659

Type of visit: Case Management - Deficiencies

On 5/25/23 at approximately 11:00am Licensing Program Analyst (LPA) Maja Jensen arrived at facility to conduct a case management for deficiencies observed during the course of complaint investigation #27-AS-20230303123659. LPA Jensen met with Justice Ehimamiegho and explained the purpose of today's visit. On 3/21/23 at approximately 11:00am, a department investigator conducted an interview with Resident 9 (R9) and observed that R9 appeared unkempt with what was believed to be human feces on the side of his sweatpants. Deficiencies are being cited from the California Code of Regulations. Failure to correct deficiencies may result in the assessment of civil penalties.the state’s words, verbatim · CDSS document, May 25, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jun 8, 2023

Personal Rights of Residents in All Facilities Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on the Department investigator's observation of a R1 going about his daily routine with visibily soiled clothing. This poses a potential threat to health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, May 25, 2023

Plan of correction: Licensee agrees to conduct inservice training on pesonal rights by 6/8/23 and will email proof of completion to maja.jensen@dss.ca.gov

Allegation investigated: Staff do not treat residents with respect Staff yell at residents Staff do not serve food of quantity to meet the needs of residents Staff threaten residents Residents are not being fed

On 4/28/23 at approximately 1:20pm Licensing Program Analysts (LPAs) Maja Jensen and Jennifer Fain arrived facility unannounced to continue a compliant investigation in to the above listed allegations. LPAs met with Licensee Justice Ehimamiegho and explained the purpose of today's visit. During the course of the investigation LPA Jensen interviewed 7 residents, 3 staff members and 2 responsible parties. LPA Jensen also observed meal service and the interactions between staff and residents on 3 separate occasions 3/6/23, 3/24/23 and 4/28/23. With respect to the allegations the following determinations were made based on LPA observation during the course of site visits and the interviews conducted: Continued on LIC 9099C... Unsubstantiated Staff do not treat residents with respect 6 of 7 residents interviewed advised they are always treated with respect. 2 responsible parties for clients in care stated they had no concerns regarding how clients are treated. 3 of 3 staff members stated they have never witnessed another staff member treat clients without respect. Based on interviews conducted and observations made during 3 separate site visits this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that while the allegation may have happened, the preponderance of evidence does not prove it. Staff yell at residents 7 of 7 residents interviewed advised staff has never yelled at them. 2 responsible parties for clients in care stated they had no concerns regarding how clients are treated. 3 of 3 staff members stated they have never personally yelled at clients or witnessed another staff member yell at clients. Based on interviews conducted and observations made during 3 separate site visits this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that while the allegation may have happened, the preponderance of evidence does not prove it. Staff threaten residents 7 of 7 residents interviewed advised staff has never threatened them. 2 responsible parties for clients in care stated they had no concerns regarding how clients are treated. 3 of 3 staff members stated they have never personally threatened clients or witnessed another staff member threatened clients. Based on interviews conducted and observations made during 3 separate site visits this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that while the allegation may have happened, the preponderance of evidence does not prove it. Staff do not serve food of quantity to meet the needs of residents 7 of 7 residents interviewed advised they receive an adequate quantity of food. 2 responsible parties for clients in care stated they had no concerns regarding how clients are treated. Based on interviews conducted and observations made by LPA Jensen during meal service this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that while the allegation may have happened, the preponderance of evidence does not prove it. Continued on LIC 9099C... Residents are not being fed 7 of 7 residents interviewed advised they are always fed. 2 responsible parties for clients in care stated they had no concerns regarding how clients are treated. Based on interviews conducted and observations made by LPA Jensen during meal service this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that while the allegation may have happened, the preponderance of evidence does not prove it. No deficiencies were cited as a result of this visit. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 28, 2023 · control 27-AS-20230303123659

Type of visit: Case Management - Deficiencies

On 4/28/23 at approximately 9:30am Licensing Program Analysts (LPAs) Maja Jensen and Jennifer Fain arrived at facility unannounced to conduct a case management for a report related to a resident that left the facility unsupervised. LPAs Jensen and Fain met with Licensee Justice Ehimamiegho and explained the purpose of today's visit. LPA Jensen was notified by local law enforcement that on 4/20/23 at approximately 4pm, resident 5 (R5) left the facility unsupervised. R5 was not reported missing until 08:23am on 4/21/23. At that time law enforcement canvassed the neighborhood and located the resident. LPA Jensen also reviewed an incident report sent on 4/22/23 that indicated R5 left the facility on 4/20/23 after dinner and did not return until the next day after being found by the police. LPA Jensen reviewed staff care notes that indicated R5 left the facility but no specifics were noted on where the R5 was going or when she would be back. LPA Jensen reviewed the resident sign out log and observed that R5 had signed out but there was no time of sign out or destination noted. Deficiencies are being cited from the Health and Safety Code (HSC), Title 22, Division 6. An immediate $1000 civil penalty is also being assessed. Failure to correct deficiencies may result in additional civil penalties and administrative action. An exit interview was conducted and a copy of this report was given.the state’s words, verbatim · CDSS document, Apr 28, 2023

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(d) · Plan of correction due date: Apr 28, 2023

Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: ... Being aware of the resident's general whereabouts, although the resident may travel independently in the community. This requirement was not met as evidenced by: Based on LPA Jensen's review of an incident report and the written account received by email from local law enforcement officer, resident R5 was outside of the facility and reported as missing from the afternoon of 4/20/23 to the morning of 4/21/23. This poses an immediate threat to the health, safety and personal rights of resident in care.the state’s words, verbatim · CDSS document, Apr 28, 2023

Plan of correction: The Licensee agrees to obtain a new physician's report to assess any changes in condition of the resident and to update the needs and service plan based on R5's current condition. Licensee will email LPA Jensen at maja.jensen@dss.ca.gov evidence that an appointment has been scheduled.

Type of visit: Case Management - Other

On 4/28/23 at approximately 3:15pm Licensing Program Analysts (LPAs) Maja Jensen and Jennifer Fain arrived at facility unannounced to conduct a case management in order to follow up on action items identified during the legal/non-compliance conference held on 4/12/23. LPA Jensen met with Licensee Justice Ehimamiegho and explained the purpose of today's visit. The following updates were obtained: Licensees stated they will do the following to achieve continued and substantial compliance (updates are in BOLD text): · Immediately identify 2 medical transports companies in the area to provide non-emergency transport-AMR and CMS were contacted, they advised no contract is needed and that services can be requested as needed · Immediately ensure Administrator presence for a minimum of 40 hours a week-Stephenie Siewe will submit Administrators certification application no later than Monday May 1, 2023 and until then Licensee is at facility 40 hours a week and has a current certification. · Immediately refrain from accepting or retaining residents determined by a physician to have a primary diagnosis of a mental disorder unrelated to dementia-Immediately complied with · The licensee will evaluate the current STD850 to ensure that they are in compliance with the state Fire Marshall; The facility has a non ambulatory fire clearance for each room that will be used to accommodate a resident with dementia within 2 days; submit an updated LIC200 and facility sketch.-Email sent to LPA Jensen within the required time frame. Continued on LIC 809C.... · Submit a new LIC 500 by 04/17/23 · Submit an Activity Calendar within 2 days · In 7 days comply with all regulations specific to facilities licensed for a capacity of 16 or greater OR seek a decrease in capacity · Conduct a self assessment of all resident and personal files within 30 days and make needed updates per requirements. · Have all food preparation staff ServSafe certified within 30 days. · Utilize an off site training for Mandated Reporting and de-escalation within 30 days · Engage the residents in the menu process within 30 days and document preferences. · Assess and replace mattresses and/or waterproof mattress sleeves within 90 days. · Review and Amend the current incontinence plan to be approved by the Department within 90 days.the state’s words, verbatim · CDSS document, Apr 28, 2023

Type of visit: Case Management - Other

On 3/24/23 at approximately 11:30am Licensing Program Analyst Maja Jensen arrived at facility to conduct a case management related to an observation made during a site visit on 3/19/23. On 3/19/23 LPA Jensen was conducting interviews with Resident who advised she had a pre-existing injury-a foot fracture. LPA Jensen observed some swelling to the foot. R1 stated she was not in pain and did not want a cast as a cast may cause atrophy. LPA Jensen also observed R1 had an overgrown toe nail that was overgrown by approximately 1 inch however R1 again denied experiencing pain. LPA Jensen returned on this day to conduct a case management for R1. LPA Jensen requested the file for Resident 1 (R1) and reviewed all records. LPA Jensen interviewed site manager and was advised that the facility has a podiatrist that visits the facility however the podiatrist has not been at the facility since R1 was admitted which was approximately 4 weeks ago. LPA Jensen again interviewed R1 and recommended podiatry care. R1 declined assistance with seeking medical attention for the toe. R1 confirmed she recently had an appointment with her PCP but was unable to complete the appointment as she did not have her ID and insurance. R1 is being established as a new patient with a local Primary Care Provider (PCP). The site manager has confirmed they will assist R1 in establishing as new patient and getting seen by the PCP. LPA Jensen also returned 2 resident files for Resident 2 and Resident 3 that were taken to the Regional Office for the purpose of making copies in relation to separate complaint investigation. No deficiencies are being cited as a result of this case management. An exit interview was conducted and a copy of this report was given to care staff Isaiah Trotter.the state’s words, verbatim · CDSS document, Mar 24, 2023

Allegation investigated: Facility is not clean Facility is malodorous

On 3/20/23 at approximately 10am Licensing Program Analysts (LPAs) Maja Jensen and Jennifer Fain arrived at facilty unannounced to continue an investigation into the above listed allegations. LPAs Jensen and Fain met with Stephanie Siewe. LPA Jensen and Fain toured the facility including grounds, dining room, kitchen, bathrooms and resident rooms. LPA Jensen observed 1 of 2 refrigerators were malfunctioning. Upon entering the kitchen, the refrigerator on the left hand side nextb to the office was approximately 55 degrees. The refrigerator contained left over food in a carry out container, soda, cookies. The refrigerator was sticky to the touch. The freezer contained juice and milk. The contents of the freezer were not frozen and the freezer was observed to be slightly cooler the refrigerator portion. LPA Jensen also observed rust and broken rubber seals around the preimeter of the refrigerator. Photos were taken. Continued on LIC 9099C... Substantiated LPA Jensen interviewed care provider Stephanie Siewe. She stated that sometimes the refrigerator functions properly and sometimes it does not. When the Administrator is present he can usually set the circuit breaker in order to make it function properly. LPA Jensen instructed care provider and cook to discard all food product from the malfunctioning refrigerator. LPA Jensen interviewed 3 residents and 1 responsible party. 2 residents were interviewed in their rooms and 1 resident and one responsible party was interviewed outside. LPA Jensen observed stains on the walls in a bedroom and chewed sunflower shells behind a night stand in the same room. LPA Jensen also observed a discarded mattress and damaged chairs being stored in the back yard. LPA Jensen attempted to interview a resident in a resident bedroom privately but was unable to shut the door as it was broken. The door was either out of alignment or had expanded beyond the size of the door frame and would not shut properly. LPA Jensen observed blood on the linen of resident sheets and pillow case. In the dining room by the wall with the clock, on the floor next to the hallway LPA Jensen observed approximately 20 half inch diameter stains on the floor and food remnants. LPA Jensen detected an odor of urine emanating from a residents room. LPA Jensen also detected an odor of urine during the course of site visits on 3/6/23 and 3/9/23. Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties. An exit interview was conducted and a copy of this report and appeal rights were provided to care provider Stephanie Siewe.the state’s words, verbatim · CDSS document, Mar 20, 2023 · control 27-AS-20230303123659

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Mar 23, 2023

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Based on LPA Jensen's observation of chewed sunflower seed shells on floor, stains on walls, stains on floor, broken bedroom door and discarded mattress and chairs in backyard. This poses a potential risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Mar 20, 2023

Plan of correction: The Licensee will submit a plan by 3/23/23 to maja.jensen@dss.ca.gov to come in to compliance with this regulation by 3/27/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Mar 23, 2023

...the licensee shall be responsible for the following: ... Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. Based on LPA Jensen's detection of an odor related to urine or feces on 3 separate occasions. This poses a potential risk to the health, safety and personal rights to residents in care.the state’s words, verbatim · CDSS document, Mar 20, 2023

Plan of correction: The Licensee will submit a plan by 3/23/23 to maja.jensen@dss.ca.gov to come in to compliance with this regulation by 3/27/23.

Allegation investigated: Lack of supervision causing residents to AWOL.

On 03/16/2023 at approximately 3 pm. Licensing Program Analyst (LPA) Renee Campbell arriveed unannounced to deliver findings for the complaint above. LPA met with Caregiver Isaiah Trotter and explained the purpose of the visit. During the investigation, Licensing Program Analyst (LPA) Renee Campbell reviewed records for 2 residents in reference to 2 AWOL incidents. Facility provided 602, Needs and Services plans and the incident reports for both residents. Galt police provided call logs and/or police reports for the months of October to January and the responding officer was interviewed. Of the two resident files reviewed, none were allowed to leave the facility unassisted. Only R2 left the facility without staff supervision. When R2 left the facility, he went to the bus stop alone. Staff were not reported to have gone with him. Per the responding officer, no staff were with the resident when he returned to the facility. The only staff on shift remained at the facility. Cont This record was amended and updated on 04/12/23. Substantiated This agency has investigated the complaint alleging that residents are AWOL due to lack of supervision. Based on interviews and a review of records, there was a lack of supervision for this resident. As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency(ies) cited on the LIC 9099-D, per Title 22 Regulations, Division 6 and a civil penalty is assessed. Exit interview conducted. Copy of report, LIC 9099-D, and appeal rights provided. Failure to correct any deficiency(ies) by plan of correction due date(s) may result in civil penalties.the state’s words, verbatim · CDSS document, Mar 16, 2023 · control 27-AS-20230118092636

From the deficiency page — Deficiency type: Type A · Section cited: CCR 1569.312(d) · Plan of correction due date: Apr 20, 2023

1569.312(d) - Basic Service Requirements. Every facility...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 Based on review of police documentation for a found person(A missing person / found person on 01/10/23) This poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Mar 16, 2023

Plan of correction: Licensee shall conduct in-service training with staff to go over how staff shall ensure that residents don't AWOL. Licensee shall submit the date for the training and send a signature sheet of all staff who attended to LPA by POC date.

Type of visit: Case Management - Deficiencies

On 3/6/23 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to open a complaint investigation-See complaint number 27-20230303123659. LPA Jensen met with Licensee Justice Ehimamiegho and explained the purpose of today's visit. LPA Jensen interviewed Licensee Justice who confirmed that the facility does not currently have a functioning signal system that operates from each resident room. This facility is licensed for 18 residents and therefore requires a functioning signal system . Deficiencies are being cited from the California Code of Regulations (CCR), Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties. In addition, the facility was cited on 2/23/23 for having an inoperable washing machine. The citation gave a Plan of Correction with a due date 3/2/23 to submit a repair receipt or replacement receipt. To date no invoices have been submitted. LPA Jensen interviewed the Licensee who stated that the machine is under warranty and he is waiting on the vendor to receive parts or if they are unable to obtain the needed part they will replace the unit. Civil penalties are being assessed for failure to correct deficiencies. Further failure to correct deficiencies may result in administrative action. An exit interview was conducted and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 6, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1) · Plan of correction due date: Mar 20, 2023

All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit. (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. (C) Identify the specific resident living unit. This requirement was not met as evidenced by: LPA's observation of the facility call system being inoperable and interview with Licensee who confirmed that the facility does not currently have a working signal system. This poses a potential risk to teh health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Mar 6, 2023

Plan of correction: The Licensee agrees to install a signal system by 3/20/23 and will email a receipt to maja.jensen@dss.ca.gov

Allegation investigated: Facility staff does not provide resident(s) with clean linens.

Licensing Program Analyst (LPA) Renee Campbell and Licensing Program Manager (LPM) Liza King arrived at the facility at 10:54 am to follow up on a complaint investigation. LPM met with a staff member and toured the facility including the resident bathroom, kitchen, 4 resident rooms.. During the Facility Tour, LPA and LPM noted a strong urine odor. However, clean linens were seens on the beds in residents rooms and observed clean linens stored in the laundry area. Beds were made and appeared to be clean. Although clean linen was present, a citation was issued for a broken washing machine in a case management during today's visit. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies were cited for the allegation that the staff does not provide residents with clean linens. Exit interview conducted. Report provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 23, 2023 · control 27-AS-20230118092636

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Facility staff does not properly store/prepare food.

Licensing Program Analyst (LPA) Renee Campbell and Licensing Program Manager (LPM) Liza King arrived at the facility at 10:54 am to follow up on a complaint investigation. LPM met with a staff member and toured the facility including the resident bathroom, kitchen, 4 resident rooms. LPM observed 3 days of perishables including fruits and vegetables. Frozen items included one item in a garbage bag which resembled beef, unlabeled, with ice chips and exposed meat, another item which appeared to be beef, one package of chicken, one pork roast exposed to the freezer with packaging damaged and meat appeared dry and another pork roast packaged appropriately. In the refrigerator there were 4 containers ranging in size that were unlabeled. Several jarred containers were opened without an opened label. Based on todays observations this allegation is substantiated meaning, the preponderance of evidence standard has been met. Citations were issued and appeals rights were provided during an exit interviiew with Caregiver Stephanie Siewe Ehimamiegho.. Substantiatedthe state’s words, verbatim · CDSS document, Feb 23, 2023 · control 27-AS-20230118092636

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(9) · Plan of correction due date: Mar 3, 2023

87555 general food services Procedures which protect ... food shall be observed in food storage, preparation and service. This requirement is not met as evidenced by Based on observation, interviews and record review freezer burned food, opened packages of frozen meat and unlabeled food item were found in the refrigerator and freezer.the state’s words, verbatim · CDSS document, Feb 23, 2023

Plan of correction: Facility will correctly packege food items with dates and a description of the item by POC date.

Allegation investigated: Licensee did not report to the licensing agency within the agency's next working day and a written report should be submitted to licensing within seven days following the occurrence of such event.

Licensing Program Analyst (LPA) Renee Campbell and Licensing Program Manager Liza King, made an unannounced visit to Ehimas to deliver the findings of a complaint investigation. LPA Campbell discussed the purpose of the visit and the elements of the allegation with Caregiver Stephanie Siewe Ehimamiegho During the investigation, LPA collected Resident #1’s (R1) physician report, staff notes, incident reports, needs and service plan and admission agreement. LPA also interviewed the administrator and five collaborating agency personnel. Based on Incident reports, Administrator did report prior visits of R1 to the hospital and when R1 was placed on 5150. The visits that occurred on 10/11/22, 12/03/22 and 12/07/22 were reported and submitted to licensing as required. This agency has investigated the complaint alleging that the licensee did not report incidents to the licensing agency . We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No deficiencies, Exit Interview Conducted. Unfoundedthe state’s words, verbatim · CDSS document, Feb 23, 2023 · control 27-AS-20221209083147

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: The licensee did not mail or fax to the Department a copy of the 30-day written notice in accordance with (a) above within five days of giving the notice to the client.

At approximately 11:00 am on 02/23/23, Licensing Program Analyst (LPA) Renee Campbell and Licensing Program Manager Liza King, made an unannounced visit to Ehimas to deliver the findings of a complaint investigation. LPA Campbell discussed the purpose of the visit and the elements of the allegation with . Caregiver Stephanie Siewe Ehimamiegho During the investigation, LPA collected Resident #1’s (R1) physician report, staff notes and needs and service plan. LPA also interviewed the administrator and five collaborating agency personnel. Although W1 informed the regional office that the administrator reported that he did not want the resident to return to the facility following R1’s 5150 hold, interviews with four other collaborating agency staff members including mental health, placement and payee service, were unable to corroborate the allegations of W1. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies, Exit Interview Conducted. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 23, 2023 · control 27-AS-20221209083147

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Renee Campbell and Licensing Program Manager (LPM) Liza King arrived at the facility at 10:54 am to follow up on a complaint investigation. LPM toured the facility including the resident bathroom, kitchen, resident rooms and reviewed 2 Resident files, further follow up is needed. Beds were made and appeared to be clean with no presense of saturation. An odor of urine was however present throughout the facility. LPM and LPA observed the activity in the facility for approximately an hour and casually spoke to residents. During the facility tour, the LPM observed One resident room which contained a tape like fly trap hanging from the ceiling covered in dead flies photo taken. During the tour and interview, a staff member reported that the washing machine is inoperable and facility staff are doing laundry off site, which may be a factor in the odor of the building. Based on the above observations, a citation was issued. An exit interview was conducted with the staff member and report was provided via email to Justice, during the visit..the state’s words, verbatim · CDSS document, Feb 23, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)((2) · Plan of correction due date: Feb 23, 2023

Personal Rights:(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.The facility failed to meet this as evidenced by: A fly trap full of dead flies was hanging from the ceiling in the middle of a resident room.the state’s words, verbatim · CDSS document, Feb 23, 2023

Plan of correction: Fly trap was removed during visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(g)(1) · Plan of correction due date: Mar 2, 2023

Maintenance and Operation: (g) Facilities which have machines and do their own laundry shall: (1) Have adequate supplies available and equipment maintained in good repair. This was not met as evidenced by an inoperable washing machine.the state’s words, verbatim · CDSS document, Feb 23, 2023

Plan of correction: Facility will provide proof of repqair or relacement within 7 days to renee.campbell@dss.ca.gov

Allegation investigated: Resident sustained unexplained bruising while in care.

On 11/30/2022 at 9:00 am, LPA Campbell and LPA Bilger came to facility unannounced to continue a complaint on the allegations noted above. LPA’s met with Justice Osase Ehimamiegho and explained the purpose of the visit. Allegation states resident received an unexplained injury while in care. LPA reviewed the following documents: 911 call logs, police reports and requested 602 for Resident 2(R2) as well as needs and service plan for R2. LPA also interviewed R1 , police, family and administrator Justice Osase Ehimamiegho. When questioned by the police, resident denied having a desire to hurt himself on the date of the incident on 8/19/2022. Based on staff statements and resident records, R2 has a history of banging his head into the wall and did sustain an injury on 8/19/22 that was observed by staff. Additionally, based on review of needs and service plan for R2 dated 8-7-22, facility staff identified R2's behavior of constantly banging head on wall with intervention to include 1:1 observation cont. to LIC9099-C Substantiated cont from LIC9099. Based on LPAs observations, interviews, and record reviews, there is a preponderance of evidence to conclude that R2 sustained unexplained injuries while in care due to lack of appropriate monitoring of R2's needs, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An immediate civil penalty of $500 is issued in addition to citation issued. .the state’s words, verbatim · CDSS document, Nov 30, 2022 · control 27-AS-20220822135344

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.321(e) · Plan of correction due date: Dec 1, 2022

1569.321(e) Every facility...shall provide at least the following basic services: (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety and well-being. Based on interviews and record reviews, the license did not provide the 1:1 observation requirement per the needs and services plan. This poses a potential Health, Safety or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 30, 2022

Plan of correction: Licensee will audit all resident charts and current staffing schedules to ensure adequate monitoring and supervision of resident needs. Licensee will submit a completion date for audit by POC due date. Audit to completed no later than 2 weeks from date of citation issuance.

Allegation investigated: Resident sustained injuries (including a fracture) while in care. Facility failed to seek timely medical care

On this date, 01/27/2023, LPA Renee Campbell visited the facility to amend a complaint report containing inaccurate visit date. A follow up visit from the 11/30/22 visit noted below was conducted on 01/19/22 to deliver the findings of the investigation, however dates of signatures were not corrected in the reporting system. On 11/30/2022 at approximately 9:00 am, LPA Campbell and LPA Bilger came to facility unannounced to continue a complaint on the allegations noted above. LPA’s met with Justice Osase Ehimamiegho and explained the purpose of the visit. During the course of the investigation LPA conducted interviews with staff and residents who reported no incidents of injury or falls. The assigned social worker reported no recent spinal injuries on the date of the incident and the alleged victim refused to grant access to his medical records for further information. In regard to any alleged assault, the victim has now reversed his story and stated no one had hurt him. Based on interviews and record reviews, the preponderance of evidence standard is not met, and this allegation is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Nothe state’s words, verbatim · CDSS document, Nov 30, 2022 · control 27-AS-20221019101734

Type of visit: Case Management - Deficiencies

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 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. ,the state’s words, verbatim · CDSS document, Nov 17, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 1569.312(d) · Plan of correction due date: Dec 19, 2022

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 Based on review of police documentation for a missing person report on 09/15/22.. This poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Nov 17, 2022

Plan of correction: 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. .

From the deficiency page — Deficiency type: Type B · Section cited: CCR97411(a) · Plan of correction due date: Dec 19, 2022

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: 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.the state’s words, verbatim · CDSS document, Nov 17, 2022

Plan of correction: 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.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(D) · Plan of correction due date: Dec 19, 2022

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: 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.the state’s words, verbatim · CDSS document, Nov 17, 2022

Plan of correction: 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.

From the deficiency page — Deficiency type: Type B · Section cited: CCR1569.50(a)(3) · Plan of correction due date: Dec 19, 2022

(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: 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.the state’s words, verbatim · CDSS document, Nov 17, 2022

Plan of correction: 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).

Type of visit: Required - 1 Year

On November 1, 2022 at 3:59PM Licensing Program Analyst (LPA) Chris Hopkins arrived at Ehimas Residential Care for the purpose of conducting an unannounced required 1 year annual inspection. LPA verified there were no active covid cases. LPA met with caregiver Stephanie Siewe. Administrator, Justice Ehimamiegho showed up at a later time. LPA evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA measured the water temperature, temperature measured at 107 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven-day non-perishable and two-day perishable food supplies. Fire extinguishers and smoke and carbon monoxide detectors are in compliance with fire safety. First aid kit was checked and is complete. LPA observed centrally stored medications, toxins, and sharps kept locked and inaccessible to clients. LPA reviewed Fingerprint clearance and associations to the facility. The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. Common touch surfaces are cleaned every 4 hours. LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 500 personnel report, LIC 610E Emergency Disaster Plan, Current Administrator Certificate and copy of Liability Insurance. Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Nov 1, 2022

Allegation investigated: Residents sleep in wet beds and clothes Facility Staff are not adequately supervising residents Facility staff are not ensuring that residents diapers are changed Facility is in disrepair

On 10/05/2022 at 9:45 am, LPA Campbell and LPA Bilger came to facility unannounced to continue a complaint investigation for the allegations noted above. LPA's met with Administrator Justice Ehimamiegho and explained the purpose of the visit. During the course of this investigation, four residents, Administrator and three staff were interviewed as well as a facility observation 08/19/22, 08/31/22 and 10/05/22. LPA's reviewed facility menu and staffing schedule. Allegation #3 Residents sleep in wet beds and clothes. Allegation #4 Facility Staff are not adequately supervising residents and Allegation #5 Staff are not ensuring diapers are changed. Based on interviews and observations, it was determined that night staff do not consistently change clients overnight and residents clothes and bedding are soaked through by morning. LPA also observed a strong smell of urine during the first investigative visit on 08/31/22. Based on interviews, it was determined residents have to change their diapers overnight if they are able. Due to a preponderance of evidence, this allegation is SUBSTANTIATED. Allegation 6, Facility is in disrepair. LPA observed bathrooms had no lightbulbs, there was a crack in one of the toilets and the area around the toilet base was chipped and cratered. Paint in the dining area was chipped and had food stains. Due to a preponderance of evidence, this allegation is SUBSTANTIATED. Substantiatedthe state’s words, verbatim · CDSS document, Oct 5, 2022 · control 27-AS-20220817141052

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Nov 8, 2022

87411(a) Facility personnel shall all times be ... competent to provide the services necessary to meet resident needs... This requirement is not met as evidenced by Based on observation, interviews and record review, the licensee did not ensure adequate personnel provided incontinent care overnight. This poses a potential Health, Safety or Personal Rights risk to residents in care..the state’s words, verbatim · CDSS document, Oct 5, 2022

Plan of correction: Licensee will conduct staff training on incontinent care and provide the staff training materials used along with proof of completed training (staff sign in sheet) by POC due date. Licensee will notify LPA of training date on 10/12/2022.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Nov 8, 2022

87625(b)(3) ... the licensee shall be responsible for ... Ensuring that incontinent residents are kept clean and dry and ... the facility remains free of odors from incontinence. This requrement is not met as evidenced by Based on observation and interviews, the licensee did not ensure residents were kept clean and dry resulting in a strong urine odor.the state’s words, verbatim · CDSS document, Oct 5, 2022

Plan of correction: Licensee will conduct staff training on incontinent care and provide the staff training materials used along with proof of completed training (staff sign in sheet) by POC due date. Licensee will read regulations and provide a signed declaration of understanding by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Nov 8, 2022

87303(a) Maintenance Operation. The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by Based on observation and interviews, the licensee has not conducted basic maintenance for the bathrooms and dining room walls.the state’s words, verbatim · CDSS document, Oct 5, 2022

Plan of correction: Licensee will ensure dining room walls are cleaned, chipped drywall repaired and repainted and install secure light fixtures in the bathroom. Licensee will take pictures once the changes are made and email LPA at renee.campbell@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(2) · Plan of correction due date: Nov 8, 2022

87625(b)(2) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. This requirement is not met as evidenced by Based on observation and interviews, the licensee did not ensure overnight staff adequately checked and changed residents in care.the state’s words, verbatim · CDSS document, Oct 5, 2022

Plan of correction: Licensee will conduct staff training on incontinent care and provide the staff training materials used along with proof of completed training (staff sign in sheet) by POC due date. Licensee will read regulations and provide a signed declaration of understanding to LPA by POC due date.

Allegation investigated: Facility dishes are not properly washed Facility does not provide residents adequate food (no snacks).

On 08/31//2022 at 10 am, LPA Campbell and LPA Bilger came to facility unannounced to continue a complaint investigation for the allegations noted above. LPA's met with Administrator Justice Ehimamiegho and explained the purpose of the visit. Facility observation was completed on 8-19-22. In addition, Administrator and Staff1 (S1) were interviewed on 8-19-22. Allegation #1 Facility dishes are not properly washed. Based on interviews, it was determined that facility dishwasher was not functioning properly for over 1 week.. LPA observed that staff was hand washing dishes and based on interview found that they were not using a proper sanitizing agent per regulatory requirements.. As a result, the preponderance of evidence standard is met, therefore this allegations is SUBSTANTIATED. Allegation #2 Facility does not provide residents adequate food (no snacks). During a tour of the facility's kitchen area and outside storage area, LPA observed a locked shed. When staff opened the shed upon request, LPA observed an inadequate amount of snacks necessary for the amount of people in the facility. Additionally, LPA observed an inadquate amount of snacks available in the kitchen area. Based on observation, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. Substantiatedthe state’s words, verbatim · CDSS document, Aug 31, 2022 · control 27-AS-20220817141052

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(3) · Plan of correction due date: Aug 31, 2022

General Food Service (b) The following food service requirements shall apply: (3) Between-meal nourishment or snacks shall be made available for all residents unless limited by dietary restrictions prescribed by a physician. This requirement was not met as evidenced by Based on observation, facility did not maintain adequate amounts of snacks for residents in care. This poses a potential health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Aug 31, 2022

Plan of correction: Facility will submit 30 days worth of food receipts indicating the amounts of food provided.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(31)(B) · Plan of correction due date: Aug 31, 2022

General Food Service (b)The following food service requirements shall apply: (31) Dishes and utensils shall be disinfected: (B) In facilities not using mechanical means,... the addition of a sanitation agent to the final rinse water. This requiremebnt was not met as evidenced by Based on observation and interview, Facility did not use a sanitation agent while hand washing dishes in the final rinse. This poses a potential health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Aug 31, 2022

Plan of correction: Facility will buy a new dishwasher that will maintain hot water at a minimum temperature of 170 degrees F (77 degrees C) at the final rinse cycle of diswashing machines or have a plan in place approved by the Department to sanitize without a dishwasher.

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

On 8-31-22 at 9:58am, Licensing Program Analysts (LPAs) Michael Bilger and Renee Campbell arrived unannounced to conduct a case management visit based on various incidents occurring between 5-20-22 and 8-19-22. LPAs met with Administrator Justice Ehimamiegho and explained the purpose of the visit. LPAs also interviewed Administrator, staff1 (S1), and reviewed facility file documentation. LPAs also reviewed police report call log. Based on record review it was determined that a total of 38 9-1-1 calls where made between the dates of 5-20-22 and 8-19-22. Upon further review, it was determined that facility did not ensure incident reports sent to Licensing department for multiple incidents occurring between this time period. In addition, during this case management, it was determined through record review that an incident occurred which resulted in a 9-1-1 call by a resident1 (R1) on 7-9-22, alerting police of an alleged altercation between R1 and R2. This same 9-1-1 call also alerted police of an alleged altercation between R2 and R3. LPAs also interviewed R2 and R3. Based on interviews and staffing schedule reviewed, it was determined that two staff members were on duty at time of alleged incident in which R1 called 9-1-1. Based on today’s case management, citations are issued under Title 22, division 6, chapter 8, and health and safety code. An exit interview was conducted with Justice Ehimamiegho and a copy of this report was left with Justice. Appeal rights provided.the state’s words, verbatim · CDSS document, Aug 31, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(D) · Plan of correction due date: Sep 1, 2022

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: Based on record review and interview, licensee did not ensure reports sent to licensing agency for multiple incidents occurring between 5-20-22 and 8-19-22. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 31, 2022

Plan of correction: Licensee will develop plan to ensure incident reports are submitted to licensing agency in a timely manner. Plan to be submitted to LPA by POC due date.

Type of visit: Case Management - Incident

Licensing Program Analysts (LPA's) Ruth Wallace and Renee Campbell conducted unannounced Case Management Visit for Incident regarding Resident (R1). LPA's met direct care staff and explained purpose of visit. LPA's reviewed R1's physician's report, staff notes, and incident report documents. R1 received surgery at hospital approximately on April 13, 2022 for a hip fracture and is recovering back at facility since April 21, 2022. No deficiencies cited on today's case management incident . LPA's conducted exit interview with direct care staff and copy of report given at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jun 7, 2022

Type of visit: Case Management - Incident

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.the state’s words, verbatim · CDSS document, Apr 21, 2022

Type of visit: Case Management - Incident

On 03/23/2022, Licensing Program Analyst (LPA),T. White, conducted an unannounced case management visit to follow up on an AWOL incident, which occurred on 02/05/2022. LPA met with Administrator, Justice Osase Ehimamiegho and explained the purpose of the visit. LPA White reviewed the incident report submitted to CCLD on 02/07/2022. Based on incident report, Resident #1 (R1) went out through the front door of the facility refusing to let staff know where he was going. Staff attempted to redirect him. R1 ignored every attempt of redirection and started running when he noticed that staff was coming towards him. R1 then made a right turn at the end of the street. Staff stopped walking towards him to avoid any further occurrence and called 911 at about 9am. Police found resident and brought him back to facility at 10am.Based on R1's Physician Report, R1 is able to leave unassisted. Administrator stated R1 was admitted to the hospital for surgery on 03/03/2022. LPA informed Administrator to contact CCL once R1 returns to the facility. LPA reviewed how the facility is working with residents to prevent further AWOLs. No deficiencies were cited today. Exit interview was conducted with Administrator and a copy of report given.the state’s words, verbatim · CDSS document, Mar 23, 2022

Type of visit: Case Management - Incident

On 01/05/2022, Licensing Program Analyst (LPA),T. White, conducted an unannounced case management visit to follow up on an AWOL incident, which occurred on 12/27/2021. LPA met with Administrator, Justice Osase Ehimamiegho and explained the purpose of the visit. LPA White reviewed the incident report submitted to CCLD on 12/28/2021. Based on incident report, Resident #1 (R1) attempted to leave the facility, but staff re-assured R1 that Administrator will talk to R1 in the morning. Staff used the bathroom then asked R1 to please hold on for a minute, but R1 left right before staff was out of the restroom. Staff looked around and immediately called 911. Police found R1 and brought R1 back to facility. Based on R1's Physician Report, R1 is able to leave unassisted. LPA confirmed the safety of the resident and reviewed how the facility is working with the resident to prevent further AWOLs. No deficiencies were cited today. Exit interview was conducted with Administrator and a copy of report given.the state’s words, verbatim · CDSS document, Jan 5, 2022

Type of visit: Case Management - Incident

On 10/13/2021, Licensing Program Analyst (LPA), T. White, conducted an unannounced case management visit to follow up on an incident submitted to CCLD on 10/06/2021. At approximately 9:30 AM, LPA met with Administrator, Justice Ehimamiegho at the entrance of the facility.LPA White's temperature was checked, logged, and then signed into the facility. Based on incident report, on 10/04/2021, Resident #1 (R1) was transported to Kaiser hospital. Administrator spoke with Kaiser Care team regarding R1's needs and relocation to a higher level of care. The Kaiser team informed Administrator, higher level of care will not help R1. R1 is an adult and makes his own decisions. Based on interview with Administrator, R1 was not eating at the facility and Administrator suggested R1 be relocated to higher level of care. The Kaiser team informed Administrator there is nothing a higher level of care will be able to do. Administrator stated R1 returned back at the facility on 10/06/2021 and has since been eating. On 10/13/2021, LPA observed R1 in the facility, watching television and eating. No deficiencies cited during inspection. Exit interview conducted with Administrator and a copy of report given.the state’s words, verbatim · CDSS document, Oct 13, 2021

Type of visit: Case Management - Incident

On 10/01/21, Licensing Program Analyst (LPA), Mohamed Filouane, conducted an unannounced case management visit to follow up on an AWOL incident, which occurred on 9/22/21. At approximately 9:55 AM, LPA met with staff member, Ricardo Rodriguez, at the entrance of the facility. LPA was sanitized following the facility's entrance health and safety procedures. LPA also had his temperature checked and logged and then signed into the facility. LPA Filouane reviewed the incident report submitted to CCLD with the staff member. LPA confirmed the safety of the resident and reviewed how the facility is working with the resident to prevent further AWOLs. Staff stated that the facility employees have spoken with the resident in question to further prevent the resident from leaving the facility alone. According to facility staff, this resident has a history of attempting to go on walks to the store alone. The staff member stated that while working, they check the TV area every five to ten minutes to confirm all residents are present. The resident's roommate will also check on the resident in question, according to staff. No deficiencies were cited today. Exit interview was conducted with staff member Ricardo Rodriguez and a copy of this report was emailed to the Administrator.the state’s words, verbatim · CDSS document, Oct 1, 2021

Type of visit: Required - 1 Year

On 09/17/21, Licensing Program Analyst (LPA), Mohamed Filouane, conducted an unannounced 1-year required infection control inspection. At approximately 12:35 PM, LPA met with a staff member at the entrance of the facility. LPA was sanitized following the facility's entrance health and safety procedures. LPA also had his temperature checked and logged and then signed into the facility. At approximately 12:40 PM, LPA spoke with Administrator Justice Ehimamiegho over the phone, explained the purpose of the visit, and was told the Administrator would arrive within twenty minutes. LPA Filouane conducted a tour of the facility alone while facility staff were working and attending to the residents. The physical plant is consistent with the submitted facility sketch/floor plan and has the COVID-19 health and safety signage. There are no obstructions blocking indoor and outdoor passageways. No pools or bodies of water observed. The facility's kitchen is free of debris. At 12:45 PM, LPA observed the facility's restrooms as clean and equipped with hand washing signage. The facility's backyard was free of debris. The clients' bedrooms were inspected and all had required lighting and furniture. Facility was equipped with smoke detectors and carbon monoxide detectors. LPA also observed the fire extinguishers as current. The facility's first aid kit included the required tweezers, scissors, and a thermometer. Cleaning solutions are stored and locked. At approximately 12:50 PM, LPA completed the self-tour of the facility. At approximately 1:00 PM, the Administrator arrived in the facility. LPA reviewed facility procedures for visitation entrance, temperature checks and logs, COVID-19 isolation, and PPE, food and cleaning supply storage. This report was reviewed with the Administrator. No deficiencies were cited today. Exit interview conducted with the Administrator. A copy of this report will be emailed to the Administrator.the state’s words, verbatim · CDSS document, Sep 17, 2021