515002008-6-25-2020-25-AS-RLBN-BR3Q3D-20200630114831

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 515002008
Report Date: 06/25/2020
Date Signed: 06/25/2020 11:22:53 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASETT RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/12/2020 and conducted by Evaluator Misty Valencia

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20200312102423

FACILITY NAME:	EMERALD OAKS		FACILITY NUMBER:	515002008
ADMINISTRATOR:	BAKER, BECKY		FACILITY TYPE:	740
ADDRESS:	2290 FORREST LANE		TELEPHONE:	(530) 751-0511
CITY:	YUBA CITY	STATE: CA	ZIP CODE:	95993
CAPACITY:	99	CENSUS: 57	DATE:	06/25/2020
		UNANNOUNCED	TIME BEGAN:	09:14 AM
MET WITH:	Becky, Baker, Administrator		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Personal rights

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Misty Valencia conducted an unannounced complaint visit and met with Becky, Baker, Administrator regarding allegations: Personal rights.

Facility staff failed to provide adequate supervision resulting in Resident (R1) eloping from facility, sustaining serious injuries and accepting a client beyond their level of care. File review of documents and staff interviews indicated that R1 had wondering behavior and was at risk for elopement. Although R1’s needs and services plan does not indicate he requires one on one care, it is clear from file review documentation and staff interviews that he required more supervision than the facility could provide to prevent wondering and eloping. Staff interviews all indicate that R1 showed exit seeking behaviors, yet R1 was not provided additional supervision. Safety measures including one to two-hour checks for supervision and alarms were active at the front doors were in place for R1 from wondering.
Continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Misty Valencia	TELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2020

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 25-AS-20200312102423

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASETT RD., STE. 170
CHICO, CA 95926

FACILITY NAME: EMERALD OAKS	FACILITY NUMBER: 515002008
	VISIT DATE: 06/25/2020

NARRATIVE

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On 01/28/2020 R1 was left alone in the facility lobby while the Nocturnal Shift (NOC) shift caregiver conducted safety checks on other residents. The facility only has one NOC shift caregiver and one NOC shift medication technician (med tech) on staff for 54 residents. Staff checked on R1 at approximately 0530hours and realized R1 was missing. At 0610hours staff assumed that R1 walked out the front door lobby. NOC shift does not recall hearing the front door alarms sound off.

File review of documents and staff interviews indicted that R1 had exiting seeking behaviors and was an elopement risk. Facility did not provide adequate supervision resulting in R1 eloping. R1 was found in an orchard by a neighbor and emergency services were called. Medical records document that R1 sustained major injuries including broken ribs, major left-hand laceration, bruises, cuts and marks to left side of his body.

File review documents show that R1 is diagnosed with dementia, has wondering behavior, is not able to leave the facility unassisted, requires special observation/night supervision due to confusion and forgetfulness, and R1 is an elopement risk. Facility accepted R1 aware of R1’s wandering behavior, elopement risk and need for special night supervision. Facility planned on converting a portion of the facility to a memory care unti, but accepted R1 prior to the completion. Staff interviews indicated that Facility did not provide special overnight supervision for R1 and provide R1 an eviction notice on 01/10/2020 reporting that R1 requires more supervision than the facility can provide.

Based on this information and investigation findings conducted by the department, the allegations are substantiated.

Based on the evidence obtained, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D. As a result of R1 sustaining serious bodily injury, the violation warrants a civil penalty assessment. At this time the civil penalty assessment is under review and a civil penalty determination is pending. The LPA will return at a future date to assess the penalty. Failure to correct the deficiencies may also result in civil penalties. Appeal rights were provided and exit interview conducted.

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Misty Valencia	TELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 25-AS-20200312102423

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASETT RD., STE. 170
CHICO, CA 95926

FACILITY NAME: EMERALD OAKS	FACILITY NUMBER: 515002008
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/25/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/29/2020 Section Cited CCR 87705(c)(4)	1 2 3 4 5 6 7	87705(c)(4) Care of Persons with Dementia.(c)Licensees who accept and retain residents with dementia...(4) There is an adequatenumber of direct care staff to support each resident’s physical...	1 2 3 4 5 6 7	Licensee agrees to immediately increase staffing levels to meet the residents needs at the facility to avoid residents being left alone.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: based on observation/interview/record review the licensee did not ensure that more than one staff was on shift when a resident eloped resulting in resident’s injuries.	8 9 10 11 12 13 14	Licensee to send in LIC 500 showing increased staffing levels by 06/15/2020
Type A 06/29/2020 Section Cited CCR 87761(C)(1)	1 2 3 4 5 6 7	87761(C)(1) an immediate penalty of $500.00 per day shall be assessed for any of the following:(1) Sickness, injury or death of a client has occurred as a result of the deficiency.	1 2 3 4 5 6 7	Administrator will provide a written facility policy outlining elopement prevention. Policy to be received to CCL by 06/29/2020
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: based on observation/interview/record review the licensee did not ensure resident was unable to elope from the facility causing hospitalization.	8 9 10 11 12 13 14

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: Rayna L Bryson	TELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Misty Valencia	TELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2020

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 25-AS-20200312102423

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASETT RD., STE. 170
CHICO, CA 95926

FACILITY NAME: EMERALD OAKS	FACILITY NUMBER: 515002008
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/25/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/29/2020 Section Cited CCR 87705(j)	1 2 3 4 5 6 7	87705(j) Care of Persons with Dementia. The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.	1 2 3 4 5 6 7	Licensee agrees to immediately install a new device or fix such device that is already in place so the auditory device is functioning.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: based on observation/interview/record review the licensee did not ensure that any auditory devices in place when facility accepts dementia	8 9 10 11 12 13 14	A written plan acknowledging that the device is working and will remain in working order will be sent to CCL by 06/29/2020
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Rayna L Bryson	TELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Misty Valencia	TELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2020

LIC9099 (FAS) - (06/04)

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