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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601128
Report Date: 05/13/2025
Date Signed: 05/13/2025 03:11:14 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/05/2021 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20211105095643
FACILITY NAME:EMERALD HOME CAREFACILITY NUMBER:
015601128
ADMINISTRATOR:NICA, JOHNFACILITY TYPE:
740
ADDRESS:7314 EMERALD AVE.TELEPHONE:
(925) 398-8807
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY:6CENSUS: DATE:
05/13/2025
UNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Carmen Nica/Licensee and
John Nica/Administrator 		TIME COMPLETED:
03:15 PM
ALLEGATION(S):
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-Resident (R1) not provided call equipment/buzzer.
-Staff is charging for services not received.
-Staff did not follow admission agreement.
-Resident (R1) did not receive medication as prescribed.
-Staff did not meet resident's (R1) hygiene needs.
-Staff did not properly dress a resident (R1) while in care.
-Staff made an unauthorized diagnosis of a resident (R1) while in care.
-Staff denied visits to resident (R1) while in care.
INVESTIGATION FINDINGS:
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On this day, May 13, 2025 at 1:25 pm, Licensing Program Analyst (LPA) Delmundo conducted an unannounced visit to continue the investigation of the above allegations and close the complaint. LPA met with Carmen Nica, licensee, and informed the reason for visit. John Nica, administrator (ADM) arrived at around 2:10 pm.

On 11/10/21, LPA conducted inspection and interviewed staff (S1 and S2) and resident (R2). R1’s family member (FM) was also interviewed on 11/08/21. Licensee was also interviewed.

R1 had moved out from Emerald Care Home when complaint was received by the Department. LPA obtained copies of R1’s following documents from the facility where R1 moved-in: LIC601 Identification and Emergency Contact Information and LIC602A Physician’s Report facility Staff. On 11/10/21, LPA interviewed witness (W1) and R1.
.......continued on 9099C (page 2)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 15-AS-20211105095643
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: EMERALD HOME CARE
FACILITY NUMBER: 015601128
VISIT DATE: 05/13/2025
NARRATIVE
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Page 2

Allegation: Resident (R1) not provided call equipment/buzzer.
FM stated R1 was not provided call buzzer/call pendant. The 2 staff interviewed stated R1 had call bell which LPA observed in the vacant room used by R1 when R1 was at the facility. R1 stated she had buzzer. Due to medical diagnosis, LPA was not able to obtain information from another resident (R2). Therefore, the allegation is unsubstantiated.

Allegations:
· Staff is charging for services not received.
· Staff did not follow admission agreement.
FM stated the contract states residents would be bathed 2 times per week and that was not
adhered to even after the family brought this issue to the licensee, they found R1 lacking proper hygiene with greasy matted hair and dressed in the same blouse 3 days in the same week. Review of Admission Agreement for R1 showed bathing twice a week. LIC602A Physician’s Report showed substantial assistance with bathing and partial to substantial assistance with dressing and grooming.

S1 stated residents are given bath on Wednesdays and Saturdays. S1 denied missing giving bath to R1 and stated that she remembers giving R1 a bath 3x in a week, because R1 had an accident. S1 further stated that FM came one time and said something about R1's hair being dirty and that was day after R1 was given the scheduled bathing, so S1 gave R1 a shower that day. S2 stated all residents get a bath Wednesdays and Saturdays but R1 sometimes refused but at the end of the day, R1 still get bathe. She and S1 give bath to R1 because of R1’s medical condition and cannot take care of own bathing needs.

R1 stated not remembering how many times staff gave R1 a bath, however, R1 told LPA regarding R1's medical condition.

S1 stated R1 loves wearing dress sleep wear and that she changed R1's dress every day. S1 further stated she cleaned and wiped R1’s underarm and body with warm cloth every single day. S2 stated she changes all residents clothes every day. R1 stated that it never happened that R1 wore the same clothing for days. Licensee stated residents are changed everyday when they get up and before they go to bed
...continued 9099C (page 3)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20211105095643
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: EMERALD HOME CARE
FACILITY NUMBER: 015601128
VISIT DATE: 05/13/2025
NARRATIVE
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Page 3

During inspection, LPA observed R2 wearing clean clothing; however, due to R2’s medical condition, LPA was not able to obtain information regarding the allegations. Therefore, the allegations are unsubstantiated.

Allegation: Resident did not receive medication as prescribed.
FM stated that licensee, told FM that the Milk of Magnesia had not been stated and gave the FM the medication to administer to R1. Licensee denied the allegation and that she and ADM are the one who administers medications to residents. S1 stated she does know if licensee asked FM to administer the said medication. S2 stated not hearing the licensee asked FM to administer the said medication. R1 stated she does not believe she was taking Milk of Magnesia while at the facility, but list of medications showed R1 has order for this medication. Therefore, the allegation is unsubstantiated.

Allegation: Staff did not meet resident's (R1) hygiene needs.
FM stated that R1 would be bathe twice a week per contract which facility failed to provide. FM further stated that R1 was lacking proper hygiene with greasy, matted hair. Review of Admission Agreement for R1 showed bathing twice a week. S1 and S2, stated they gave R1 bath two times a week. S1 also stated she R1 a bath 3x a week when R1 had accident while S1 stated R1 sometimes refused but at the end of the day, R1 gets bathe. S1 further stated that when FM came and observed R1’s hair, R1 was given a bathe day prior. Licensee stated residents are given bath 2 to 3 times a week as agreed and given sponge bath on days residents are not scheduled for bathing; however, residents are given bath when they have accidents. R1 was not able to provide information regarding the frequency of bathing provided to R1. Due to R2’s medical diagnosis, LPA was not able to obtain information. Therefore, the allegation is unsubstantiated.

Allegation: Staff did not properly dress a resident (R1) while in care.
FM stated that R1’s lower half was not dressed for facility’s convenience and instead wrap a pad and blanket around R1’s lower extremities. S1 stated R1 loves wearing pajama. Both S1 and S2 stated they change residents’ clothes every day. Licensee denied the allegation and stated the residents' clothing are changed when they get up and before they are put to bed.

....continued on 9099C (page 4)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20211105095643
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: EMERALD HOME CARE
FACILITY NUMBER: 015601128
VISIT DATE: 05/13/2025
NARRATIVE
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Page 4

R1 stated care staff has taken good care of her. W1 stated observing R1 has blanket from waist down when she assessed R1, however, W1 was not able to tell if R1 was wearing something from waist down or if R1 was wearing a full dress. Due to R2’s medical diagnosis, LPA was not able to obtain information whether R2 observed R1 not dressed from waist down. Therefore, the allegation is unsubstantiated.

Allegation: Staff made an unauthorized diagnosis of a resident (R1) while in care.
FM stated the licensee repeatedly described R1 as having dementia. Review of LIC602A did not show R1 has dementia diagnosis. The licensee denied the allegation and stated that she never told the FM that R1 has dementia but mentioned that it could be mild cognitive impairment. S1 and S2 stated not hearing the licensee saying R1 has dementia. Due to R2’s medical diagnosis, LPA was not able to obtain information pertaining to the allegation. Therefore, the allegation is unsubstantiated.

Allegation: Staff denied visits to resident (R1) while in care.
FM stated that licensee told R1’s family leave R1 there for some time after admission meaning not visiting regularly R1 so R1 would fall into line with the house rules. The licensee …… . S1 and S2 stated R1’s family member came to the facility every day and was allowed to visit R1 and the visitation took place in the backyard. Residents’ visitations were allowed inside the facility after weeks and visitors wore mask. R1 was not able to provide information. Due to R2’s medical diagnosis, LPA was not able to obtain information. Therefore, the allegation is unsubstantiated.

Based on interviews, observation and records review, there is not a preponderance of evidence standard to prove that violation occurred.

No deficiency cited. Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4