Resident rights
Cited in 2 reports, with 3 deficiencies in total.
EHIMAS RESIDENTIAL CARE
407 MAPLE STREET, Galt CA 95632
15 bedsLatest official report Sep 18, 2025Licensed
Additional info
- Telephone
- (916) 912-8042
- Licensee
- EHIMAS RESIDENTIAL CARE LLC
- Administrator
- STEPHANIE SIEWE
- Contact
- STEPHANIE SIEWE
- License first date
- Nov 2, 2020
- License effective date
- Nov 2, 2020
- District office
- SACRAMENTO SOUTH ASC · (916) 263-4700
- Regional office
- 27
- Clients served
- 983 - RCFE / DEMENTIA
Summary
The available records show 13 Type A and 25 Type B deficiencies for this facility.
- Most recent inspection
- Sep 18, 2025
- Most recent deficiency
- Oct 14, 2024
7 later reports, from Oct 29, 2024 through Sep 18, 2025, recorded no deficiencies, though the records do not say whether they were follow-ups.
What Type A and Type B mean
- Type A
- Violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
- Type B
- Violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care.
Both classifications are published by California CDSS and are shown as published. SeniorLivingFacts does not rename them or add a severity level of its own.
At a glance
Counts cover the five-year public record. Typical figures are the median for the 17 Sacramento County facilities licensed for 7 to 15 beds, except where too few exist to state one — those come from facilities with 7 or more beds.
In the available public five-year record, CCLD published 56 reports for this facility: 29 inspections, 24 complaint investigations, and 3 licensing or administrative records.
Those records contain 13 Type A and 25 Type B deficiencies.
0 deficiencies have explicit official correction or clearance evidence in the loaded records.
- Official inspections
- 29
- Recorded deficiencies
- 38
- Type A deficiencies
- 13
- Type B deficiencies
- 25
- Substantiated complaints
- 7
- Repeated topics
- 1
More than the typical 10
1 in the last 12 months
Well above the typical 8
0 in the last 12 months
Well above the typical 4
0 in the last 12 months
Well above the typical 4
0 in the last 12 months
Well above the typical 2
0 in the last 12 months
Last 36 months
Repeated topics
Topics cited in more than one report during the last 36 months. A repeat may show a pattern worth asking about. Each date opens its report below.
Official report history
All preserved reports from the most recent to the oldest, sortable by report type.
Inspection
No deficiencies recorded in this report
Complaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 6 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 3 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportInspection
No deficiencies recorded in this report
Complaint
Allegations1 substantiated · 9 unsubstantiated · 0 unfounded · 1 cited
Medical and dental careType A
- Official classification
- Type A
- Official code
- 87465(e)
- Regulation authority
- CCR
What the official deficiency says
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.
Official 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.
Deadline recorded: Oct 15, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Oct 15, 2024
Correction not verified in available records
Inspection
No deficiencies recorded in this report
Inspection
Resident rightsType A
- Official classification
- Type A
- Official code
- 87468.2(a)(4)
- Regulation authority
- CCR
What the official deficiency says
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.
Official 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.
Deadline recorded: Apr 9, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Apr 9, 2024
Correction not verified in available records
Food serviceType A
- Official classification
- Type A
- Official code
- 87555(b)(26)
- Regulation authority
- CCR
What the official deficiency says
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.
Official 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.
Deadline recorded: Apr 9, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Apr 9, 2024
Correction not verified in available records
Records and plan of operationType B
- Official classification
- Type B
- Official code
- 87506(a)
- Regulation authority
- CCR
What the official deficiency says
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.
Official 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.
Deadline recorded: May 10, 2024. A deadline is not proof that correction was completed.
Corrective action observedRecorded in report dated Apr 8, 2024
Plan of correction recorded
Correction deadline recordedDeadline May 10, 2024
Inspection
No deficiencies recorded in this report
Inspection
No deficiencies recorded in this report
Inspection
No deficiencies recorded in this report
Licensing recordNot an inspection of the operating facility
Licensing and administrationType B
- Official classification
- Type B
- Official code
- 87213
- Regulation authority
- CCR
What the official deficiency says
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.
Official 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
Deadline recorded: Nov 27, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Nov 27, 2023
Correction not verified in available records
Licensing and administrationType B
- Official classification
- Type B
- Official code
- 87216(a)
- Regulation authority
- CCR
What the official deficiency says
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.
Official 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.
Deadline recorded: Nov 3, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Nov 3, 2023
Correction not verified in available records
Resident rightsType B
- Official classification
- Type B
- Official code
- 87217(a)
- Regulation authority
- CCR
What the official deficiency says
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.
Official 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.
Deadline recorded: Nov 3, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Nov 3, 2023
Correction not verified in available records
Resident rightsType B
- Official classification
- Type B
- Official code
- 87218(a)
- Regulation authority
- CCR
What the official deficiency says
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.
Official 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.
Deadline recorded: Nov 3, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Nov 3, 2023
Correction not verified in available records
Administrator qualificationsType B
- Official classification
- Type B
- Official code
- 87405(b)
- Regulation authority
- CCR
What the official deficiency says
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.
Official 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.
Deadline recorded: Nov 3, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Nov 3, 2023
Correction not verified in available records
Licensing and administrationType B
- Official classification
- Type B
- Official code
- 87755(b)
- Regulation authority
- CCR
What the official deficiency says
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.
Official 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.
Deadline recorded: Nov 3, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Nov 3, 2023
Correction not verified in available records
Complaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportInspection
Dementia careType B
- Official classification
- Type B
- Official code
- 87705
- Regulation authority
- CCR
What the official deficiency says
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.
Official plan of correction
Administrator will email a plan of correction by 9/15/23 to jennifer.fain@dss.ca.gov
Deadline recorded: Sep 15, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Sep 15, 2023
Correction not verified in available records
Admission, assessment, and evictionType A
- Official classification
- Type A
- Official code
- 87204
- Regulation authority
- CCR
What the official deficiency says
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.
Official plan of correction
Administrator will email a plan of correction by 9/15/23 to jennifer.fain@dss.ca.gov
Deadline recorded: Sep 15, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Sep 15, 2023
Correction not verified in available records
Licensing recordNot an inspection of the operating facility
No deficiencies recorded in this report
Complaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Resident rightsType A
- Official classification
- Type A
- Official code
- 87468.2(a)(4)
- Regulation authority
- CCR
What the official deficiency says
(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.
Official 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.
Deadline recorded: Aug 25, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Aug 25, 2023
Correction not verified in available records
Complaint
Allegations1 substantiated · 1 unsubstantiated · 0 unfounded · 1 cited · investigated over 2 visits
No deficiencies recorded in this reportInspection
No deficiencies recorded in this report
Licensing recordNot an inspection of the operating facility
No deficiencies recorded in this report
Inspection
Medical and dental careType A
- Official classification
- Type A
- Official code
- 87465(a)(1)
- Regulation authority
- CCR
What the official deficiency says
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.
Official 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.
Deadline recorded: Aug 18, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Aug 18, 2023
Correction not verified in available records
Admission, assessment, and evictionType A
- Official classification
- Type A
- Official code
- 87463(a)
- Regulation authority
- CCR
What the official deficiency says
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.
Official 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.
Deadline recorded: Aug 17, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Aug 17, 2023
Correction not verified in available records
Complaint
Part of the complaint whose outcome is recorded on Aug 25, 2023 · Control 27-AS-20230227143013
Resident rightsType A
- Official classification
- Type A
- Official code
- 87468.2(a)(4)
- Regulation authority
- CCR
What the official deficiency says
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.
Official 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.
Deadline recorded: Aug 18, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Aug 18, 2023
Correction not verified in available records
Inspection
No deficiencies recorded in this report
Complaint
Allegations4 substantiated · 8 unsubstantiated · 2 unfounded · 3 cited · investigated over 4 visits
Resident rightsType B
- Official classification
- Type B
- Official code
- 87468.2(a)(4)
- Regulation authority
- CCR
What the official deficiency says
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 care
Official 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.
Deadline recorded: Jul 19, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Jul 19, 2023
Correction not verified in available records
Inspection
No deficiencies recorded in this report
Inspection
No deficiencies recorded in this report
Inspection
Resident rightsType B
- Official classification
- Type B
- Official code
- 87468.1(a)(1)
- Regulation authority
- CCR
What the official deficiency says
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.
Official 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
Deadline recorded: Jun 8, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Jun 8, 2023
Correction not verified in available records
Complaint
Part of the complaint whose outcome is recorded on Jul 18, 2023 · Control 27-AS-20230303123659
No deficiencies recorded in this reportInspection
Licensing and administrationType A
- Official classification
- Type A
- Official code
- 1569.312(d)
- Regulation authority
- HSC
What the official deficiency says
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.
Official 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.
Deadline recorded: Apr 28, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Apr 28, 2023
Correction not verified in available records
Complaint
Part of the complaint whose outcome is recorded on Jul 18, 2023 · Control 27-AS-20230303123659
No deficiencies recorded in this reportInspection
No deficiencies recorded in this report
Inspection
No deficiencies recorded in this report
Complaint
Part of the complaint whose outcome is recorded on Jul 18, 2023 · Control 27-AS-20230303123659
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87303(a)
- Regulation authority
- CCR
What the official deficiency says
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.
Official 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.
Deadline recorded: Mar 23, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Mar 23, 2023
Correction not verified in available records
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87625(b)(3)
- Regulation authority
- CCR
What the official deficiency says
...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.
Official 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.
Deadline recorded: Mar 23, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Mar 23, 2023
Correction not verified in available records
Complaint
Allegations2 substantiated · 0 unsubstantiated · 1 unfounded · 2 cited · investigated over 3 visits
Licensing and administrationType A
- Official classification
- Type A
- Official code
- 1569.312(d)
- Regulation authority
- CCR
What the official deficiency says
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.
Official 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.
Deadline recorded: Apr 20, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Apr 20, 2023
Correction not verified in available records
Inspection
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87303(i)(1)
- Regulation authority
- CCR
What the official deficiency says
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.
Official 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
Deadline recorded: Mar 20, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Mar 20, 2023
Correction not verified in available records
Inspection
Resident rightsType B
- Official classification
- Type B
- Official code
- 87468.1(a)
- Regulation authority
- CCR
What the official deficiency says
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.
Official plan of correction
Fly trap was removed during visit.
Deadline recorded: Feb 23, 2023. A deadline is not proof that correction was completed.
Corrective action observedRecorded in report dated Feb 23, 2023
Correction deadline recordedDeadline Feb 23, 2023
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87303(g)(1)
- Regulation authority
- CCR
What the official deficiency says
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.
Official plan of correction
Facility will provide proof of repqair or relacement within 7 days to renee.campbell@dss.ca.gov
Deadline recorded: Mar 2, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Mar 2, 2023
Correction not verified in available records
Complaint
Part of the complaint whose outcome is recorded on Mar 16, 2023 · Control 27-AS-20230118092636
No deficiencies recorded in this reportComplaint
Part of the complaint whose outcome is recorded on Mar 16, 2023 · Control 27-AS-20230118092636
Food serviceType B
- Official classification
- Type B
- Official code
- 87555(9)
- Regulation authority
- CCR
What the official deficiency says
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.
Official plan of correction
Facility will correctly packege food items with dates and a description of the item by POC date.
Deadline recorded: Mar 3, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Mar 3, 2023
Correction not verified in available records
Complaint
Allegations0 substantiated · 1 unsubstantiated · 1 unfounded · investigated over 2 visits
No deficiencies recorded in this reportComplaint
Part of the complaint whose outcome is recorded on Feb 23, 2023 · Control 27-AS-20221209083147
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 2 unsubstantiated · 2 unfounded
No deficiencies recorded in this reportComplaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Licensing and administrationType A
- Official classification
- Type A
- Official code
- 1569.321(e)
- Regulation authority
- HSC
What the official deficiency says
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.
Official 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.
Deadline recorded: Dec 1, 2022. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Dec 1, 2022
Correction not verified in available records
Inspection
Licensing and administrationType A
- Official classification
- Type A
- Official code
- 1569.312(d)
- Regulation authority
- CCR
What the official deficiency says
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.
Official 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. .
Deadline recorded: Dec 19, 2022. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Dec 19, 2022
Correction not verified in available records
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 97411(a)
- Regulation authority
- CCR
What the official deficiency says
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.
Official 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.
Deadline recorded: Dec 19, 2022. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Dec 19, 2022
Correction not verified in available records
Incident reportingType B
- Official classification
- Type B
- Official code
- 87211(a)(D)
- Regulation authority
- CCR
What the official deficiency says
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.
Official 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.
Deadline recorded: Dec 19, 2022. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Dec 19, 2022
Correction not verified in available records
Resident rightsType B
- Official classification
- Type B
- Official code
- 1569.50(a)(3)
- Regulation authority
- CCR
What the official deficiency says
(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.
Official 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).
Deadline recorded: Dec 19, 2022. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Dec 19, 2022
Correction not verified in available records
Inspection
No deficiencies recorded in this report
Complaint
Allegations7 substantiated · 3 unsubstantiated · 0 unfounded · 6 cited · investigated over 2 visits
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87411(a)
- Regulation authority
- CCR
What the official deficiency says
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..
Official 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.
Deadline recorded: Nov 8, 2022. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Nov 8, 2022
Correction not verified in available records
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87625(b)(3)
- Regulation authority
- CCR
What the official deficiency says
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.
Official 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.
Deadline recorded: Nov 8, 2022. A deadline is not proof that correction was completed.
Citation dismissed - not a correctionOn Nov 8, 2022
Deficiency Dismissed Type B 11/08/2022 Section Cited CCR 87625(b)(3)
Plan of correction recorded
Correction deadline recordedDeadline Nov 8, 2022
Correction not verified in available records
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87303(a)
- Regulation authority
- CCR
What the official deficiency says
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.
Official 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
Deadline recorded: Nov 8, 2022. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Nov 8, 2022
Correction not verified in available records
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87625(b)(2)
- Regulation authority
- CCR
What the official deficiency says
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.
Official 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.
Deadline recorded: Nov 8, 2022. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Nov 8, 2022
Correction not verified in available records
Inspection
Incident reportingType A
- Official classification
- Type A
- Official code
- 87211(a)(D)
- Regulation authority
- CCR
What the official deficiency says
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.
Official 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.
Deadline recorded: Sep 1, 2022. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Sep 1, 2022
Correction not verified in available records
Complaint
Part of the complaint whose outcome is recorded on Oct 5, 2022 · Control 27-AS-20220817141052
Food serviceType B
- Official classification
- Type B
- Official code
- 87555(b)(3)
- Regulation authority
- CCR
What the official deficiency says
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.
Official plan of correction
Facility will submit 30 days worth of food receipts indicating the amounts of food provided.
Deadline recorded: Aug 31, 2022. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Aug 31, 2022
Correction not verified in available records
Food serviceType B
- Official classification
- Type B
- Official code
- 87555(b)(31)(B)
- Regulation authority
- CCR
What the official deficiency says
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.
Official 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.
Deadline recorded: Aug 31, 2022. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Aug 31, 2022
Correction not verified in available records
Inspection
No deficiencies recorded in this report
Inspection
No deficiencies recorded in this report
Inspection
No deficiencies recorded in this report
Inspection
No deficiencies recorded in this report
Inspection
No deficiencies recorded in this report
Inspection
No deficiencies recorded in this report
Inspection
No deficiencies recorded in this report
1 complaint has no published investigation report
The official record holds these complaints, but no investigation report was published for them. Their outcome is shown as the source recorded it.
- Dec 7, 2023 · Control 27-AS-20230913171522
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
Source and limits
California Department of Social Services, Community Care Licensing Division. Public facility history is described by the source as a five-year window. Older records and previous-licensee history may require a regional-office request. Type 741 RCFE-CCRCs, nursing homes, and other care settings are excluded from this page.
Read the data methodology