515002008-4-5-2022-25-AS-MTHO-CD7PVZ-20220405113959

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 515002008
Report Date: 04/05/2022
Date Signed: 04/05/2022 11:40:13 AM

Document Has Been Signed on 04/05/2022 11:40 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR:	SANDHU, SUKHJIT		FACILITY TYPE:	740
ADDRESS:	2290 FORREST LANE		TELEPHONE:	(530) 751-0511
CITY:	YUBA CITY	STATE: CA	ZIP CODE:	95993
CAPACITY:	0	CENSUS: 0	DATE:	04/05/2022
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Galen Fillmore, Licensee		TIME COMPLETED:	11:45 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 4/5/2022, Licensing Program Analysts (LPAs) Mai Thao and Jaclyn Avila met with Galen Fillmore, Licensee, to follow up on a substantiated allegation of neglect/lack of supervision. Due to change of ownership, this report was delivered to Licensee’s home in Gridley, CA and not at the facility. Prior to visit, LPAs completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPAs ensured they applied hand sanitizer before entering the location and the following Personal Protective Equipment (PPE) was worn: N95 Mask. On June 25, 2020, the Department conducted a complaint investigation which alleged the following: Personal Rights violations to include neglect/lack of supervision as well as accepting a client beyond their level of care. Both allegations were substantiated, and the licensee was cited for violating California Code of Regulation (CCR) Title 22, § 87705(c)(4) Care of Persons with Dementia and CCR Title 22, § 87761(c)(1) Penalties for a $500 immediate penalty for sickness, injury or death of a client occurring as a result of the deficiencies were assessed. On January 28, 2020, the resident (R1) who was diagnosed with dementia and wandering tendencies was left unattended and R1 eloped from the facility. While R1 was unattended, R1 escaped into a neighboring orchard where R1 sustained multiple subacute left-side rib fractures, a major left-hand laceration, bruises, cuts, and marks to the left side of the body. (continue 809-C......)

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Mai Thao	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/05/2022

NARRATIVE

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The investigation revealed that R1 moved into Emerald Oaks on November 29, 2019. R1’s medical evaluation report (LIC 602) from June 21, 2019, diagnosed R1 with dementia and documented that R1 was unable to leave a facility unassisted. On January 28, 2020, R1 wandered from Emerald Oaks alone and was subsequently found at a neighboring orchard. Facility staff (S1) last had contact with R1 at approximately 5:30 a.m. and did not notice R1 was missing until approximately 6:10 a.m. S1 contacted Sutter County Sheriff’s at 7:15 a.m. to file a missing person’s report, when they were informed that R1 was recently located. Local Sheriffs responded to a previous AWOL call made at 6:59 a.m. by a neighbor, resulting in R1 being picked up by EMS and taken to the hospital due to injuries observed. The treating paramedics documented the cause of the injury to be a blunt fall. The acute care hospital staff diagnosed R1’s injuries as broken ribs, bruised knees, and a hand injury.

Based on a review of the medical report, R1 was brought in by a local ambulance and was found having eloped from the facility. Following a physical examination, R1 was discharged from the hospital to another hospital for further treatment, as it had been recommended by the hospital Social Worker that R1 be discharged to a higher level of care due to R1’s memory care needs.

Based on staff interviews, it was determined that S1 was conducting safety checks on other residents and had asked Med Tech (S2) to watch R1 when R1 exited the property. Staff interviews revealed S2 was in the medications room preparing for crossover with the morning shift. It was also reported that S1 and S2 were the only staff on duty for the entire facility at the time of R1's elopement. Staff interviews further revealed that R1 had eloped from the facility at least twice prior to the January 28, 2020, elopement. Interviews conducted with facility Administrator state that the facility does accept memory care residents, however they do not have a separate memory care wing, nor does the facility have dedicated staff to assist memory care residents. It was also stated that the facility only accepts memory care residents who they do not consider to be a flight risk. In interviews, R1’s family member stated that they told the facility staff that R1 had a history of wandering and was a flight risk. In response, R1’s family member was told by facility staff that the facility was being converted into a “lock down” facility and that the facility has two sections, assisted living and memory care. R1’s family member stated they did not observe anywhere in the facility to be “lock down.” During the course of the investigation, the Department observed that there were several facility doors that led to the outside and they were all unlocked. The Department investigator stated they observed a building alarm and a “chirper” on all doors and according to the facility Administrator, the “chirpers” were installed after the incident with R1. The facility Administrator stated that prior to the incident with R1, there was concern that the building alarms could be turned off by staff as they entered and exited the building.

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SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Mai Thao	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/05/2022

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Based on interviews and records reviewed, the licensee did not have adequate staffing on January 28, 2020, the date of R1’s elopement. There is sufficient evidence that the facility Administrator and facility caregivers were aware of R1's propensity to elope from the facility. Evidence showed one caregiver and one Med Tech were on duty for the entire facility at the time R1 eloped. Despite R1's propensity to elope, the licensee did not provide additional caregivers on duty at the time of R1's elopement. As a result of the January 28, 2020, elopement incident, R1 fell and sustained broken ribs, knee bruises, and a hand injury that required hospitalization, which is serious bodily injury.

On June 25, 2020, the facility Administrator was delivered a substantiated complaint investigation finding, and an immediate civil penalty of $500 was issued. The licensee was informed that an additional civil penalty was still being determined. The facility Administrator was informed that a civil penalty might be assessed based on Health and Safety Code § 1569.49.

The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. Per Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.”

Today, 4/5/2022, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on June 25, 2020 the amount of the civil penalty issued today will be $9,500.

A copy of the LIC 421D was given to Galem Fillmore, Licensee, and originals were signed.

Exit interview conducted. A copy of the report issued. Appeal Rights provided. Galem Filmore signature on this report acknowledges receipt of these rights, found on page two (2) of LIC 421D.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Mai Thao	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

LIC809 (FAS) - (06/04)

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