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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 515002008
Report Date: 04/19/2021
Date Signed: 04/19/2021 12:09:46 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/04/2020 and conducted by Evaluator Pheej Cheng
COMPLAINT CONTROL NUMBER: 25-AS-20201204131306
FACILITY NAME:EMERALD OAKSFACILITY NUMBER:
515002008
ADMINISTRATOR:SANDHU, SUKHJITFACILITY TYPE:
740
ADDRESS:2290 FORREST LANETELEPHONE:
(530) 751-0511
CITY:YUBA CITYSTATE: CAZIP CODE:
95993
CAPACITY:0CENSUS: 0DATE:
04/19/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rita Hammill; LicenseeTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Medication is being mishandled. Medication is going missing. Discontinued medications are not being destroyed.
INVESTIGATION FINDINGS:
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On 4/19/21 at 9 AM, Licensing Program Analyst (LPA) Cheng conducted an unannounced complaint visit via telephone and spoke to Licensee Rita Hammill. A telephone call was conducted in compliance to the department's procedures regarding COVID-19. Complaint was initially opened under facility license #515002008; however, the license is no longer active as there has been a change of ownership. Hammill provided LPA with an e-mail so that she can provide a copy of the report.

Continuation on LIC 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021
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 5
Control Number 25-AS-20201204131306
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 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: EMERALD OAKS
FACILITY NUMBER: 515002008
VISIT DATE: 04/19/2021
NARRATIVE
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Base on statements and documents obtained, LPA determined that the above allegation occurred. S1 confirmed that R1’s medication pill count was off. Statements from staff and med techs confirmed that R1’s medication was not properly logged into the facility’s Centrally Stored Medication Log; which resulted in the facility unable to determine the location of the missing medications. Facility’s documents indicate that medications are being properly destroyed and logged.

Based on LPA information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/04/2020 and conducted by Evaluator Pheej Cheng
COMPLAINT CONTROL NUMBER: 25-AS-20201204131306

FACILITY NAME:EMERALD OAKSFACILITY NUMBER:
515002008
ADMINISTRATOR:SANDHU, SUKHJITFACILITY TYPE:
740
ADDRESS:2290 FORREST LANETELEPHONE:
(530) 751-0511
CITY:YUBA CITYSTATE: CAZIP CODE:
95993
CAPACITY:0CENSUS: 0DATE:
04/19/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rita Hammill; LicenseeTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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1) No active administrator is on site.
2) Residents are not being showered.
3) Residents are not being supervised while taking medications.
INVESTIGATION FINDINGS:
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1) No active administrator is on site.

LPA was informed by Administrator Becky Baker about her resignation. Facility associated Sukjiht Sandhu as the interim Administrator after Baker had left. LPA was fully informed about the transition and employment of a new Administrator to replace Sandhu and informed his Licensing Program Manager about the situation.

Continuation on LIC 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 25-AS-20201204131306
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 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: EMERALD OAKS
FACILITY NUMBER: 515002008
VISIT DATE: 04/19/2021
NARRATIVE
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2) Residents are not being showered.

Based on statements obtained, LPA determined that there are insufficient information available. Staff interviewed stated that residents receive at least two showers a week; more if needed. Statements from residents interviewed confirmed that they are receiving. Facility has a shower aid whose duty is to only provide showering services to residents.

3) Residents are not being supervised while taking medications.



Based on statements obtained, LPA determined that there was insufficient information available. Staff statements indicate that they are to observe all residents take their medications to ensure the medications are consumed. Residents interviewed confirmed that med techs do observe residents consume the medications prior to moving on to the next resident.

Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and a copy of report was sent via e-mail.

SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 25-AS-20201204131306
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 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: EMERALD OAKS
FACILITY NUMBER: 515002008
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/19/2021
Section Cited
CCR
87465(h)(6)
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87465 Incidental Medical and Dental Care (h)(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident..This requirement was not met as evidenced by
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Licensee completed an in-service training on 1/5/2021 regarding medication documentation and provided proof to LPA via e-mail. Deficiency cleared.
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Based on statements and documents, Licensee did not maintain an accurate centrally stored medication log for 1 of 1 resident which poses a potential health and safety risk to resident in care.
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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: Rayna L BrysonTELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5