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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045003022
Report Date: 07/09/2024
Date Signed: 07/09/2024 03:17:38 PM

Document Has Been Signed on 07/09/2024 03:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:EMERALD DREAMCARE HOMEFACILITY NUMBER:
045003022
ADMINISTRATOR/
DIRECTOR:		MURILLO, AARONFACILITY TYPE:
740
ADDRESS:2289 BARTRIANGLE STREETTELEPHONE:
(925) 914-9470
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY: 6CENSUS: 5DATE:
07/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:11 PM
MET WITH:Administrator- Arron Murillo TIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On 07/09/2024, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Administrator, Arron Murillo and explained the purpose of the visit.

LPA Boyles and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, backyard, shed, and common restrooms. LPA observed the facility to be clean, in good repair and odor-free.

LPA observed each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, and trash can with lids. LPA observed each bedroom to have all the required furnishings, working lights and windows with screens. LPA observed every resident to have a hospital bed with half bed rails. Facility has a 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked. LPA observed chemicals left accessible to residents in the kitchen and in the laundry room. Hot water temperature was measured with the required temperature range. LPA observed one (1) fire extinguishers, fire detectors, and carbon monoxide detectors. LPA observed the first aid to be complete and ready for emergency use. LPA was unable to review an updated emergency disaster plan and emergency disaster drills.

LPA reviewed a total of five (5) residents' files and three (3) staff files. Resident files were missing written medical orders for half bed rails and annual medical assessments for residents with dementia. Staff files contained all of the required documentation.

Several topics were discussed.

Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code.



An exit interview was conducted, and Plans of Corrections were reviewed and developed collaboratively. A
copy of this report, LIC 809-D, and Appeal Rights were discussed and provided.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE: DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 07/09/2024 03:17 PM - It Cannot Be Edited


Created By: Jaynae Boyles On 07/09/2024 at 02:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: EMERALD DREAMCARE HOME
FACILITY NUMBER: 045003022

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that chemicals were found accessible to residents in two locations within the faciliy which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/16/2024
Plan of Correction
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The Administrator will ensure that all chemicals are locked and inaccessible to residents. The administrator will conduct a training in regards to the importance of storing chemicals inaccessible to residents, and provide proof of training to the LPA.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lauren Crocker
LICENSING EVALUATOR NAME:Jaynae Boyles
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/09/2024 03:17 PM - It Cannot Be Edited


Created By: Jaynae Boyles On 07/09/2024 at 02:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: EMERALD DREAMCARE HOME
FACILITY NUMBER: 045003022

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)(2)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that no emergency disaster plan was completed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/16/2024
Plan of Correction
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The Administrator will complete the Emergency Disaster Plan, (LIC 610E) and provide a copy to the LPA. The administrator will review the plan annually and update as needed.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in that no emergency disaster drills were conducted in the last 12 months, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/16/2024
Plan of Correction
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The Administrator will create and implement a plan to ensure emergency disaster drills are conducted annually quarterly. The Administrator will email the plan to the LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lauren Crocker
LICENSING EVALUATOR NAME:Jaynae Boyles
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/09/2024 03:17 PM - It Cannot Be Edited


Created By: Jaynae Boyles On 07/09/2024 at 02:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: EMERALD DREAMCARE HOME
FACILITY NUMBER: 045003022

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in that of the files reviewed for residents who have bed rails, there was no written order from a physician in the file which poses a potential health, safety or personal rights risk to persons in care.

POC Due Date: 07/16/2024
Plan of Correction
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The Administrator will ensure that residents with half bed rails have a written order from a physician in the file or will remove the half bed rails. Administrator will create and implement a process to ensure that written orders for half bed rails are maintained in the resident record.
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (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:
Deficient Practice Statement
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Based on observation,interview, record review, the licensee did not comply with the section cited above in that two of five resident files reviewed did not have an updated annual medical assessment which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/16/2024
Plan of Correction
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The administrator will ensure that all residents with dementia recieve annual medical assessments by creating and implementing a process to track and monitor the medical assessments for residents in care. The administrator will share this plan with the LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lauren Crocker
LICENSING EVALUATOR NAME:Jaynae Boyles
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024


LIC809 (FAS) - (06/04)
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