198601040-10-28-2025-28-AS-WSHO-DN72L7-20251106162904

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601040
Report Date: 10/28/2025
Date Signed: 10/28/2025 09:15:20 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/16/2025 and conducted by Evaluator Elizabeth Irra

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250916134210

FACILITY NAME:	EMERALD GEM HOME CARE		FACILITY NUMBER:	198601040
ADMINISTRATOR:	ELIZABETH STACY		FACILITY TYPE:	735
ADDRESS:	2420 LOGAN ST		TELEPHONE:	(909) 625-2757
CITY:	POMONA	STATE: CA	ZIP CODE:	91767
CAPACITY:	6	CENSUS: 5	DATE:	10/28/2025
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Elizabeth Stacy		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Staff physically abused resident.
Staff did not ensure resident's medical appointment was completed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elizabeth Irra conducted a subsequent visit to investigate the above allegations. LPA met with Elizabeth Stacy and discussed the purpose of today's visit.

LPA Irra conducted the initial visit on 09/25/25. During this visit, LPA obtained a copy of the Staff and Client rosters, reviewed C-1's file and obtained relevant documentation and interviewed Staff #1 (S-1) and Staff #2 (S-2). LPA was unable to interview Client #1 (C-1) and Client #3 (C-3) as both were not present at the time of this visit. LPA was unable to interview Client #2 (C-2) and Client #5 (C-5) as both are non-verbal. LPA was unable to interview Client #4 (C-4) as C-4 was asleep during this visit.

Refer to LIC 9099C for the continuation of this report.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20250916134210

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: EMERALD GEM HOME CARE	FACILITY NUMBER: 198601040
	VISIT DATE: 10/28/2025

NARRATIVE

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During the course of this investigation, LPA also interviewed Client #3 (C-3) and Client #4 (C-4) and Staff #3 (S-3) and Staff #4 (S-4). LPA left a message for Staff #5 (S-5) for a return call. LPA was unable to interview Client #1 (C-1) as C-1 is non-verbal. LPA also spoke to the Quality Assurance Representative from San Gabriel Pomona Regional Center and was informed that their investigation findings are “inconclusive”.

Allegation: Staff physically abused resident. It has been alleged that staff hit a client during a doctor’s appointment. Per staff interviews, on 09/16/25, C-1 had a medical appointment. Per S-1 and S-2 interviews, C-1 had behavioral episodes during this medical appointment. Interviewed staff indicated that C-1 began having behaviors when the medical assistant was attempting to administer C-1 with a COVID test (swab). Per interviews, C-1 became physically aggressive towards staff (grabbing and scratching) and staff redirected C-1 a couple times. Due to C-1’s on-going behavior, S-1 instructed S-2 to take C-1 back to the facility van as C-1 has a tendency of grabbing items and throwing them at others. S-1 and S-2 denied hitting/punching C-1. Interviewed staff indicated that staff do not hit (including punching) clients. Interviewed staff indicated that they have not witnessed nor received any complaints/concerns pertaining to this matter. Client interviews revealed that staff do not hit clients and have no concerns. Interviews do not corroborate this allegation.

Allegation: Staff did not ensure resident's medical appointment was completed. It has been alleged that C-1's medical appointment was not completed. Per S-1 interview, on 09/16/25, C-1 completed their appointment. Per S-1 interview, the medical personnel provided S-1 with C-1’s preparation instructions for C-1 upcoming procedure prior to leaving the doctor’s office. Per S-1, S-1 was waiting for C-1’s medical office to call S-1 and provide a date for C-1’s scheduled procedure (pending insurance approval). Interview does not corroborate this allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted. A copy of this report and appeal rights were provided to Elizabeth Stacy.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025

LIC9099 (FAS) - (06/04)

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