Ehimas Residential Care

Type of visit: Required - 1 Year

On 09/18/2025, Licensing Program Analyst (LPA) Renee Campbell arrived to the community to conduct an annual inspection. LPA Campbell entered the facility and observed residents in their rooms, socializing and/or watching TV. LPA Campbell met with Justice Ehimamiegho, Licensee and explained the purpose of the visit. LPA Campbell toured the facility and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas to ensure there are no safety hazards for residents. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 75 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The backyard was toured by LPA Campbell and pathways and exits were found to be clear. A locked food pantry shed was observed in the backyard. Staff opened the shed and canned food and a freezer filled with meat was observed. LPA Campbell observed first aid supplies and a fully-charged and up-to-date fire extinguisher. The smoke alarm system is hard wired to the fire department and consists of alarms and sprinklers. Fire System Inspections were reviewed for the prior two years and they were found to be functional. LPA Campbell observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Campbell observed locked closets and cabinets for the storage of medication. LPA Campbell observed locked storage areas for the storage of cleaning solutions and knives as well. Per California Code of Regulations (CCR's) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. An exit interview was conducted with Justice Ehimamiegho and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 18, 2025

Allegation investigated: Staff is not ensuring that medication is dispensed and prescribed to resident in care as necessary.

On 08/14/2025, Licensing Program Analyst (LPA) Renee Campbell arrived to the community to present findings for a complaint. LPA Campbell met with Licensee, Justice Ehimamiegho and explained the purpose of the visit. Regarding the allegation that staff is not ensuring that medication is dispensed and prescribed to resident in care as necessary, it was reported that R1's prescription (rx) had not been picked up since 11/2024 per R1's doctor. When LPA Campbell attempted to interview R1, R1 did not remember LPA Campbell from prior visits last week and R1 claimed her medication was fine. W1, a family friend stated R1 had trouble with long term memory. This was reiterated by the licensee. LPA Campbell reviewed R1's Medication Administration Record (MAR) and only saw a recent rx for Lisinopril from 08/2025. It was the first rx for Lisinopril since 11/2024. LPA Campbell observed the incident reported and fax confirmation report submitted by the community on 02/2025 which illustrated their continued attempts to request a new rx from the doctor without a response. The pharmacy also stated that a non-response from doctor can mean the rx is not be refilled. Unsubstantiated Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore this allegation is UNSUBSTANTIATED. Per California Code of Regulations (CCRs) - Title 22, Division 6, no deficiencies cited. Exit interview was held and a copy of report was given to Licensee, Justice Ehimamiegho.the state’s words, verbatim · CDSS document, Aug 14, 2025 · control 27-AS-20250801160942

Allegation investigated: Resident was overmedicated by staff

On 07/31/2025, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility unannounced to present findings regarding an ongoing complaint investigation. LPA Campbell met with Justice Ehimamiegho, Licensee and explained the purpose of the visit. Regarding the allegation that a resident was overmedicated by staff, LPA Campbell interviewed residents and inquired if there were any concerns regarding medicine being put in their food without their knowledge or permission? When interviewed, R5 stated staff did not dose their food with medicine. LPA Campbell also interviewed R2 and R3. Neither resident reported that staff had put medicine or laxatives in their food as reported in the complaint. After interviews, LPA Campbell found that there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur though the allegation may or may not have happened, Therefore this allegation is UNSUBSTANTIATED. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, nothe state’s words, verbatim · CDSS document, Jul 31, 2025 · control 27-AS-20250424114638

Allegation investigated: Facility is malodorous. Staff is not performing incontinent care. Staff is not administering medication as prescribed. Residents are left in bed and not provided with activities or exercise. Residents grooming needs are not being met. Staff is under the influence of drugs and/or alcohol.

This is an amended report from 08/14/2025. On 07/24/2025, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility unannounced to conduct further interviews and present findings regarding an ongoing complaint investigation. LPA Campbell met with Justice Ehimamiegho, Licensee and explained the purpose of the visit. Regarding the allegation that the facility is malodorous, during two visits on 04/29/2025 and 07/24/2025, LPA Campbell noticed no unusual or undesirable odor in the community. Regarding the allegation that staff are not performing incontinent care, R1 stated they didn't need incontinent care, but they did witness their roommate (R6) receive daily incontinence care from staff. R5 also reported that because they are non-ambulatory, staff help them with incontinence care. No residents interviewed reported staff not helping with incontinence care. Unsubstantiated Regarding the allegation that staff is not administering medication as prescribed, R3 and R2 reported that staff always offer medication as directed but they refuse to take the medication. R1 stated they take the medication offered though they don't know what the medication is for. In regards to residents shower and grooming needs, R5 reported they get showers every two days or as needed. R3 stated they take a shower ever two days vs when they were at home, where it was a shower every day. R2 reports they shower three times a week. LPA Campbell observed no stained clothing or dirty nails during interviews. No residents interviewed reported staff who were under the influence of drugs and alcohol though R1 stated they have only been present a week. The licensee reports they have not witnessed staff who were inebriated or using drugs. No staff and only one of the residents interviewed reported possible alcohol use though they could not provide names or state when it may have occurred. In regards to activities or exercise, the community keeps group activity items present in cabinets that are accessible to residents. The community has several bingo sets, puzzles and games. R2 reported that staff offer to take them on walks around the corner, Staff 2 (S2) reported taking residents to the flea market nearby and R4 stated staff have taken him to the store when asked and to doctor's appointments upon request. R5 also reported that though they cannot get up, staff always ask if they want to get up and go outside in a chair. Because it causes them pain to sit in a chair, R5 now participates in physical therapy in order to become stronger and increase their mobility. R2 reports that staff offer to take them to stores where sometimes staff will buy them a soda. During this visit, LPA Campbell also observed a Case Worker visiting residents on their case load and offer to take residents to the store if they have had their shower. During this visit, one resident had not showered and thus could not go out. Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore this allegation is UNSUBSTANTIATED. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of report was given to Justice Ehimamiegho, Licensee.the state’s words, verbatim · CDSS document, Jul 24, 2025 · control 27-AS-20250402115429

Allegation investigated: Staff inappropriately pushed a resident while in care

On 04/12/2025, Licensing Programs Analyst (LPA) Renee Campbell arrived to the facility to present findings for a complaint. LPA Campbell was met by Administrator Siewe and explained the purpose of the visit. On 01/30/2025, LPA Villanueva interviewed Staff 1 (S1). S1 stated R1 has a history of making up stories. S1 is not sure of which staff R1 was accusing of pushing R1. S1 stated R1 receives medications every month, and when it comes close to the monthly shot, R1 tends to start creating stories. S1 believes the pushing story might have happened when a staff was giving R1 support in the bathroom. On 01/30/2025, LPA Villanueva interviewed Staff 2 (S2). S2 stated that R1 has a behavioral history of making up stories and making false accusations. S2 reported to LPA instances of when R1 previously stated false allegations against the facility staff. There was an incident where R1 accused facility staff that staff are not giving R1 their cough medication that R1's doctor prescribed. R1's nurse confirmed that R1 has no prescriptions for cough nor had been to ER for cough. On 01/30/2025, LPA Villanueva attempted to contact the Reporting Party. However, a call back was not received. On 02/25/2025, LPA attempted to speak to the Reporting Party. Unsubstantiated LPA Valerio left a voicemail for a call back. A call back was not received. On 02/25/25, LPA Valerio interviewed R1. R1 stated staff are nice sometimes. When asked to explain how staff treat R1. R1 explained but then expressed R1 was talking about another resident. R1 stated a staff pushed R1 while in the shower. LPA asked who the staff member was, which R1 identified. However, when LPA asked for R1 to clarify who the staff member was R1 could not identify the staff member a second time. On 02/20/2025, LPA Valerio reviewed facility records. LPA Valerio reviewed an Unusual Incident Report dated 07/20/2024. The incident report involved R1. R1 reported that another resident killed 10 people. According to the licensee, the resident has been referred to R1 as R1's best friend and observed to be spending lots of time together. This incident occurred after R1 refused R1's monthly injection. On 02/20/2025, LPA Valerio reviewed daily notes for R1 dated 2023 until current. LPA observed daily notes that discussed other incidents that occurred with R1 and staff; however none indicate that there was an incident that occurred in the shower. Based on all the information collected by the Department, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED. California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of report was left at the facility.the state’s words, verbatim · CDSS document, Apr 10, 2025 · control 27-AS-20250122145922

Allegation investigated: Resident developed a pressure injury due to neglect Staff are not meeting resident's medical needs Staff do not assist residents with obtaining transportation

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a complaint investigation and deliver complaint investigation findings. LPA Valerio met with administrator Stephanie Siewe, and explained the purpose of the visit. The following has been determined as it relates to the aforementioned allegations. The investigation consisted of staff interviews, resident interview, review of resident records, and review of facility records. According to the Reporting Party (RP), Resident 1 (R1)had a stroke, was hospitalized, went to rehab, was discharged back to apartment, and was unable to care for herself, which resulted in R1 being hospitilized and developing an ulcer. According to RP, the facility is not getting glucose blood sugar checked, not getting blood pressure readings, and is not being assisted with medical needs or appointments. Continues on LIC 9099 - C... Unsubstantiated Continued from LIC 9099 According to the review of information provided by the RP, R1 developed an ulcer, which is not a pressure injury. According to a review of R1's LIC 602, R1 was not diagnosis with a pressure injury and did not have orders for wound care. According to a review of medication orders for R1, R1 does not have an order for the facility to check blood pressure readings. According to an interview with R1, R1 stated R1 never had any kind of wound currently and before living at Ehimas Residential Care. According to an interview with R1, R1 does not want to go to appointment nor does R1 have any appointments. R1 stated R1 wanted to move back to R1's home. R1 stated R1 does not need any type of assistance with activities of daily living (ADL); however, R1 mentioned that staff assist with baths and toileting. According to an interview with Staff 1 (S1) and Staff 2 (S2), the facility provides transportation for the residents if they do not have a ride. S1 stated the facility uses On Demand Mobility to schedule transportation if the facility vehicle is unavailable. LPA Valerio observed an invoice from On Deman Mobility on file at the facility. According to S1, R1 is not agreeable to treatment. R1 has physical therapy exercises and medical appointments but will not participate. It got to a point where the medical professionals have stated they will not come out unless R1 agrees to participate. S1 says they can encourage residents but they cannot force them. According to S2, R1's social worker did not come to see R1 until months after R1 was admitted to the facility. The social worker question specific medications, such as insulin; however, R1 never had an order for it. Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of report was left at the facility.the state’s words, verbatim · CDSS document, Dec 23, 2024 · control 27-AS-20241022100755

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual required inspection. LPA Valerio met with Administrator Stephanie Siewe, and explained the purpose of the visit. LPA Valerio and Administrator Stephanie toured the facility to ensure compliance with Title 22 regulations. LPA Valerio inspected eight (8) resident bedrooms. Resident bedrooms were observed to be fully furnished and appeared to have linens that were clean. The rooms were free from odors. Resident bathrooms were equipped with hand soap, paper towels, toilet paper, trash can, and hygiene supplies. Hot water was measured in the bathroom. Water faucets delivered hot water at 113.6 degrees F, which is within the required regulatory range. Common areas were observed to be fully furnished. The common rooms had a temperature of 76 degrees, which is within the required regulatory range. The fire extinguisher located in the kitchen and near the front entrance door to be within compliance with the last maintenance check on 10/02/2024. The kitchen was observed to be clean with sharps and chemicals locked and inaccessible to residents. Medication cabinets were locked. LPA Valerio inspected the food supply in the kitchen and in the shed refrigerator. The facility was observed to have a food supply that meets the requirements of a two day supply of perishable food items and a seven day food supply of non-perishable food items. Lunch today was observed to be top ramen and a turkey sandwich with cheese and vegetables. LPA Valerio reviewed five (5) staff files and five (5) resident files. LPA Valerio requested the following annual documentation: LIC 500, LIC 308, LIC610E, and copy of liability insurance 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, Oct 29, 2024

Allegation investigated: Staff are mismanaging resident's medication

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver complaint findings. LPA Valerio met with facility staff Eliakil Gargadi, and explained the purpose of the visit. LPA was later met by Administrator Stephanie Siewe. According to the RP, RP stated that the staff were told by Administrator Stephanie to stop giving a resident a certain medication. RP stated that there is no doctors order that says to stop the medication. On 10/14/2024, LPA Valerio observed Medication Administrator Records (MAR) for six (6) residents. Orders on the MAR matched the doctors orders and the bubble packs for 5 out of 6 residents. 6 out of 6 resident MARs were observed to have missing signatures for 10/13/2024 and AM shift on 10/14/2024. Based on records review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Per California Code of Regulation- Title 22 deficiencies are being cited. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was conducted, and a copy of the report was left at the facility. Substantiated Staff handled resident in a rough manner According to the RP, it was reported that on 06/06 or 06/07 a staff member body slammed a resident onto their bed because they did not know how to put down the grab bars. The alleged resident is on hospice and is unable to communicate. LPA Valerio interviewed the resident's roommate, Resident 5 (R5). However, R5 was unable to provide information related to the allegation. According to an interview with Staff 2 (S2), staff appear to be gentle with the resident. LPA Valerio reviewed the staff schedule for June 2024. LPA did not observe a staff member name that matched the name provided by the RP. Staff yells at residents LPA Valerio interviewed six (6) residents. R1 stated staff do not yell at us, they are nice people. R2 did not report any staff yelling at R2. R3 reported that staff are okay and they do not yell at R6 or anyone. R4 had nothing to complain about. R5 was unable to convey if staff yell or do not yell at residents. R6 reported that staff do no yell at R6. Based on interviews with three staff members (S1, S2, and S3), all staff reported that they do not raise their voice or yell at any of the residents. Staff left resident in soiled diapers for an extended period of time / Staff did not ensure the facility was free from odors According to the RP, the facility smells like ammonia due to the residents being soaked for hours from the day shift. LPA attempted to gather additional information from the RP; however, RP told LPA to go to the facility and observe it herself. LPA Valerio observed the facility on 07/02/24 and 08/08/24. During both visits, LPA Valerio did not observe any odors resulting from incontinence. LPA Valerio interviewed residents. R1 reported that staff do their rounds about 30 to 49 minutes for each resident. When R1 asks for help, R1 receives help right away. R1 reported that R1 only needs to be checked every couple of hours. R3 reported that staff are supposed to change R3's diaper; however, R3 prefers to do it themselves because they can. R5 was unable to convey if staff assist R5 with ADLs; however, LPA did not observe any signs of soiled clothing or odors. According to an interview with S1, S1 reported S1 checks on them about every hour because R1 does not want them to get a rash. According to an interview with S3, S3 reported that a noc shift staff was fired because she was caught sleeping. The staff member was an employee for a few weeks. S3 came to the facility to check on the staff. When S3 arrived, the staff was observed sleeping and did not notice S3 come in. After S3 was fired, the staff started to blame other staff for tasks that she failed to complete. Staff are not allowing residents to have water According to the RP, RP has observed a resident asking for water and another staff member will say "no! go to bed!". LPA attempted to obtain additional information from the RP; however, the RP refused to provided additional information. LPA Valerio observed the facility on 07/02/24 and 08/08/24. During both visits, LPA observed staff providing residents water, juice, or their request beverage of choice. S1 was observed getting up from the interview to provide a resident request for additional water. According to an interview with S2, the facility has a water dispenser located in the middle of the kitchen, which they used to have outside the kitchen. There was a resident that would dump the whole dispenser on the floor. Staff provide water ever hour, but the residents hate water. To help, the facility will add flavored water, which the residents enjoy. Staff did not ensure the facility was free from pests According to the RP, the facility has water bugs located all over the facility. During LPA's visits on 07/02/24, 08/08/24, and 10/14/24, there was no evidence of water bugs or other pest located in the facility. According to an interview with S2, the facility has a monthly pest control service that comes every month. S2 reported that they can be contacted as needed if anyone sees pest. LPA observed pest control invoices for April, June, and August of 2024. Staff did not ensure the facility bathroom was not in disrepair LPA Valerio observed the facility on 07/02/24 and 08/08/24. Residents have access to two out of three bathrooms. The bathroom located closest to the front door has multiple stalls, a sink, and shower to use. The second bathroom located in the middle of the hallway has one toilet, one sink, and one shower. Both restrooms were observed to be in working condition. The third bathroom is considered a staff bathroom. In order to get in, staff use a key. Based on an interview with S1, the bathroom used for staff works; however, you need to use a bucket of water to flush the toilet. According to an interview with S2, all the bathrooms work. Based on the an interview with Administrator Stephanie, the staff bathroom is currently working and you do not need a bucket to flush it. Staff are not providing a comfortable temperature for residents According to the RP, the licensee refuses to turn on the air conditioning. RP observed residents with sweat dripping down their face from it being so hot. On 07/02/24, LPA Valerio observed the front window located in the front common living room to be open. LPA Valerio observed the facility thermostat, which read a temperature of 85 degrees Fahrenheit. The temperature outside the facility upon arrival was 101.0 degree Fahrenheit and the city of Galt issued an excessive heat warning due to the temperatures rising up to 110.0 degree Fahrenheit. At 3:00 PM, the thermostat read 81 degrees and the temperature outside of the home was 108 degrees. LPA received notification of the facility temperature: 07/03/2024 at 3:00 PM - 78 degrees Fahrenheit, 07/04/2024 at 12:45 PM - 73 degrees Fahrenheit , 07/05/2024 at 9:57 AM - 70 degrees Fahrenheit, 07/05/2024 at 1:44 PM - 73 degrees Fahrenheit. On 08/08/24, the facility thermostat was set to 73 degrees Fahrenheit while fans were observed in resident bedrooms and the common hallway. Due to the above noted information, although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated. Per California Code of Regulations (CCRs) - Title 22, no deficiencies cited. An exit interview was held and a copy of report was left at the facility with Administrator Stephanie Siewe.the state’s words, verbatim · CDSS document, Oct 14, 2024 · control 27-AS-20240625121040

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(e) · Plan of correction due date: Oct 15, 2024

87465 Incidental Medical and Dental Care (e)For every prescription and nonprescription PRN medication...there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. This requirement not met as evidenced by: Based on records review, the licensee did not ensure 1 out of 6 resident files reviewed had a written order for a PRN located in the CSML and the MAR.the state’s words, verbatim · CDSS document, Oct 14, 2024

Plan of correction: The licensee will provide a plan on how to ensure medications are signed off timely by staff and ensure medications orders are up to date. LPA to receive plan by POC due date 10/15/2024.

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 Stephanie Siewe, 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 Stephanie Siewe is present for a minimum of 40 hours per week. · The licensee has not accepted any residents determined by a physician to have a primary diagnosis of a mental disorder unrelated to dementia - According to Administrator Stephanie, There have been no new admissions since the last quarterly visit. · 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 - On 01/02/2024, The facility received an updated fire clearance. The facility has a fire clearance for 15 individuals considered non-ambulatory. · Meals were observed during the visit. Today, the residents were provided waffles, sausage, and fruit for breakfast. Drinks included milk, juice, water, and coffee. LPA observed the facility to have an emergency supply of food and water, and an adequate supply of food. · Training for Mandated Reporting and De-escalation. LPA observed training files. The last training on Mandated Reporting and De-Escalation was provided on 02/27/24. Other Recent training topics were ADLs, safety, and incontinence. Per California Code of Regulations (CCR) - Title 22, no deficiencies are being cited today. An exit interview was held with Administrator Stephanie, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 8, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct a case management visit. LPA rang the door bell and was met by Resident 1 (R1). LPA introduced self and asked if any staff were present. R1 took LPA to staff. Staff was assisting another resident and mopping the floor. LPA introduced herself, and explained the purpose of the visit. LPA asked if Staff 1 (S1) was the only staff on shift. S1 was currently the only staff as Administrator Stephanie had a personal appointment. LPA was approached by Resident 1 (R1), Resident 2 (R2), Resident 3 (R3), and Resident (4) upon arrival. LPA spoke to the residents and explained the purpose of the visit. LPA Valerio was met by Administrator Stephanie roughly five to ten minutes later. According to the Administrator, Administrator Stephanie is usually at the facility. LPA requested facility files. According to the staff schedule submitted by the facility Administrator, Administrator Stephanie is scheduled from 7:00 AM - 7:00 PM along with S1, which is on schedule from 7:00 AM - 3:00 PM. Based on observations and records review, the facility did not ensure there was a sufficient number of staff to meet the needs of the residents and did not follow their staff schedule. When LPA arrived there was 1 staff member to care for 13 residents. LPA took a tour of the facility to ensure compliance of Title 22 regulations. LPA observed the facility food supply. LPA took pictures for reference. In the freezer, there was 2 loaves of bread, 3 small bags of frozen meat, and 9 small-medium freezer bags of unknown food items. The bags were labeled with a date but not what type of food in the bag. In the refrigerator, there were sauces and spices on the right door shelves, 1 large mayo container, 1 gallon of milk, 3 containers of left over food items, 2 large packages of meat, 2 bags of carrots, 1 bundle of celery, 3 bell peppers, and 7 tomatoes. In the shed in the back, there were frozen loaves of bread, 4 packs of frozen chicken, 1 large brisket, 1 family size beef. An emergency box of food were observed in the shed. For Lunch, the facility stated they were making tuna sandwiches made from the canned tuna and ravioli soup made from the canned ravioli. Based on LPA's observation, the facility did not ensure to have 2 days of perishable food items, such a fruit and vegetables. Continues on LIC 809 - C... Continued from LIC 809 LPA requested a copy of their LIC 9020 Register of Facility Clients/Residents. LPA requested 3 resident files from the list. LPA reviewed Resident 1 (R1), Resident 5 (R5), and Resident 6 (R6) files. 2 out of 3 files were observed to be incomplete. R1's file was observed to be complete with up to date information. R5's file was observed to be incomplete with a missing signature on the consent for medical treatment form. A Administrator Stephanie stated that R6's file is incomplete because the resident recently moved in. There was no admission agreement in the initial packet that Administrator Stephanie provided. LPA was provided the admission agreement, however, there were portions of the agreement that were not entirely filled out. According to R6's facility file. LPA did not observe a pre-placement appraisal or current appraisal on file. The file had an incomplete face sheet, incomplete admission agreement, Discharge Documents from previous placement, LIC 602 Physician's Report, and Medication Orders. R6 requires Oxygen daily. LPA observed R6's designated room. LPA did not observed oxygen in use signs at the door. TA was provided for the signs. According to the Licensee Justice, residents often rip the signs off from the door. LPA observed the oxygen tank and machine. According to the LIC 602, R6 is able to administer own oxygen. LPA reviewed admission agreements with rental rates. Administrator Stephanie and Licensee Justice stated there are no residents that have received an increase in rental rate. There are two residents, R1 and R5, that are in discussion based on individual circumstances. Administrator and Licensee confirmed understanding of rental increases and stated they provide notices and request signatures prior to the increase. LPA provided Technical Assistance and advised to review Health and Safety Code 1569.655, which states "...the licensee shall provide no less than 60 days' prior written notice to the residents or residents' representative setting forth the amount increase..." Per California Code of Regulations (CCR), Title 22, deficiencies are being cited on the attached LIC 809 - D page. Appeal rights were provided. An exit interview was held with Administrator Stephanie, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 8, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Apr 9, 2024

87468.2 Additional Personal Rights of Residents ...(a) In addition to the rights Section 87468.1,...:(4)To care, supervision, ... 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 observation and records review, LPA observed 1 staff on shift for 13 residents when two staff are scheduled to work for AM shift, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 8, 2024

Plan of correction: Administrator Stephanie arrived to the facility 10 minutes after LPAs arrival. Licensee stated he will submit a letter of acknowledgment and understanding of regulation 87468.2 and provide facility plans to ensure they follow their staff schedule.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87555(b)(26) · Plan of correction due date: Apr 9, 2024

87555General Food Service Requirements (b) The following food service requirements shall apply: (26)Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement was not met as evidenced by: Based on observations, the facility did not have a food supply of fruits and vegetables that met the above requirements during LPA's visit, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 8, 2024

Plan of correction: Licensee brought additional food supplies to the facility during LPAs' visit. Licensee to submit a plan of when food supplies will be restocked for April, May, and June by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: May 10, 2024

87506 Resident Records (a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility... This requirement was not met as evidenced by: Based on observations and records review, 2 out of 3 resident files were observed to be missing documentation. This poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 8, 2024

Plan of correction: Licensee stated they will ensure they complete the files for the two residents. During the visit, Administrator completed R6's file. LPA to receive copies of completed documents by POC due date.

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 Stephanie Siewe, 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 Stephanie Siewe is present for a minimum of 40 hours per week. · The licensee has not accepted any residents determined by a physician to have a primary diagnosis of a mental disorder unrelated to dementia - According to Administrator Stephanie, There have been no new admissions since the last quarterly visit. · 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 - On 01/02/2024, The facility received an updated fire clearance. The facility has a fire clearance for 15 individuals considered non ambulatory. · Meals were observed during the visit. Today, the residents were provided pancakes, eggs, sausage, and fruit slices for breakfast. Drinks included milk, juice, water, and coffee. According to Administrator Stephanie, she will prepare turkey sandwiches, chips, and homemade potato salad with drinks for lunch. LPA observed the facility to have an emergency supply of food and water. · Training for Mandated Reporting and De-escalation. LPA observed training files. The last training on Mandated Reporting and De-Escalation was provided on 12/08/2023 Per California Code of Regulations (CCR) - Title 22, no deficiencies are being cited today. An exit interview was held with Administrator Stephanie, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 12, 2024

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.