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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601128
Report Date: 08/10/2022
Date Signed: 08/10/2022 02:33:45 PM

Substantiated


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
07/21/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220721141233
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: 4DATE:
08/10/2022
UNANNOUNCEDTIME BEGAN:
01:48 PM
MET WITH:Carmen NicaTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Facility did not notify resident's responsible party of a rate increase
INVESTIGATION FINDINGS:
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On 08/10/22 at 1:48PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent complaint visit to deliver the findings of above allegation. LPA explained the purpose of the visit with administrator.

Allegation: Facility did not notify resident’s responsible party of a rate increase
Investigation Finding: Substantiated
Review of signed admission agreement show resident (R1) was admitted at the facility on 7/11/22. R1 was under hospice care and passed away on 7/18/22. R1’s personal belongings were removed from the facility by authorized representative (POA) on 7/19/22. Review of signed admission agreement dated 7/11/22 show the agreed upon total monthly rate including needed optional services for R1 was set at an agreed upon rate per month payable the 28th day of each month by licensee and POA. R1 was under hospice care while at the facility. Continued on next page LIC 9099-C

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
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-20220721141233
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: 08/10/2022
NARRATIVE
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Advanced total payment was given by POA to licensee as requirement for resident’s admittance to the facility on 7/11/22 to cover July and August 2022 monthly rate, optional services and pre-admission fee. Both licensee and R1’s POA confirmed with LPA that no written addendum to the signed admission agreement or notice explaining detailed additional services & itemized charges for higher level of care of R1 after 2 days from change in level of care at the facility was done or signed by them. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the allegation that facility did not notify resident’s responsible party of a rate increase was found to be substantiated.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D.



Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20220721141233
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/17/2022
Section Cited
HSC
1569.657(a)
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(a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative written notice of the rate increase within 2 business days after initially providing services at the new level of care. The notice shall include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges.
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By POC due date, Administrator agrees to complete and submit to CCL a copy of refund check in the amount of $ 2.877.42 to R1's POA as final reimbursement of advance payment made by POA in July 2022.
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This requirement was not met as evidenced by absence of written notice explaining the higher level of care charges 2 days after change of level of care was observed which is in violation of Title 22 H&S Section 1569.657
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Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.
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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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
07/21/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220721141233

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: 4DATE:
08/10/2022
UNANNOUNCEDTIME BEGAN:
01:48 PM
MET WITH:Carmen NicaTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Resident suffered a fall while in care
INVESTIGATION FINDINGS:
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On 08/10/22 at 1:48PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent complaint visit to deliver the findings of above allegation. LPA explained the purpose of the visit with administrator.

Allegation: Resident suffered a fall while in care
Investigation Finding: Unsubstantiated
Based on interviews and record reviews, resident (R1) had an unwitnessed fall on 07/13/22. R1 was under hospice care while at the facility, Hospice staff stated R1 slid from the half bed railing and fell that morning. Administrator and hospice staff informed authorized representative (POA) of R1’s fall the same day while visiting R1.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that R1 suffered a fall while in care which implies neglect or lack of supervision is unsubstantiated.

Exit interview conducted and a copy of this report provided via email.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4