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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 515002765
Report Date: 04/16/2021
Date Signed: 04/16/2021 01:27:45 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
12/28/2020 and conducted by Evaluator Pheej Cheng
COMPLAINT CONTROL NUMBER: 25-AS-20201228095111
FACILITY NAME:EMERALD OAKSFACILITY NUMBER:
515002765
ADMINISTRATOR:BAKER, BECKYFACILITY TYPE:
740
ADDRESS:2290 FORREST LANETELEPHONE:
(530) 751-0511
CITY:YUBA CITYSTATE: CAZIP CODE:
95993
CAPACITY:116CENSUS: 54DATE:
04/16/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ivy Garner; ED in TrainingTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff mismanaging resident's medication
INVESTIGATION FINDINGS:
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On 4/16/21 at 10 AM, Licensing Program Analyst (LPA) Cheng conducted an unannounced complaint investigation visit via telephone and spoke to Executive Director in Training Ivy Garner. A telephone call was made in compliance to the department's procedure regarding COVID-19.

Base on statements and documents obtained, LPA determined that the above allegation occurred. S1 confirmed that R1’s medication pills were 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. R1’s Centrally Stored Medication Log is confirmed that the medication was not logged into the form.
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: 04/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2021
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-20201228095111
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: 515002765
VISIT DATE: 04/16/2021
NARRATIVE
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S1 stated that since the discovery of the error, the facility has conducted an in-service training and provided documentation along with a signed staff roster of participants.

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: 04/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2021
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
12/28/2020 and conducted by Evaluator Pheej Cheng
COMPLAINT CONTROL NUMBER: 25-AS-20201228095111

FACILITY NAME:EMERALD OAKSFACILITY NUMBER:
515002765
ADMINISTRATOR:BAKER, BECKYFACILITY TYPE:
740
ADDRESS:2290 FORREST LANETELEPHONE:
(530) 751-0511
CITY:YUBA CITYSTATE: CAZIP CODE:
95993
CAPACITY:116CENSUS: 54DATE:
04/16/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ivy Garner; ED in TrainingTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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1) Resident wandered away from the facility.
2) Staff not meeting resident's hygiene needs.
INVESTIGATION FINDINGS:
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1) Resident wandered away from the facility.

Base on statements and documents obtained, LPA determined that there is insufficient information available. Statements from staff indicates that R1 has not wandered away from the facility. Staff stated that R1 is able to ambulate but not very far as she gets tired easily. Residents interviewed who knows R1 stated that R1 has never wandered from the facility. Residents interview stated that they have never wandered away from the facility either. Facility did not produce any incident reports regarding R1 leaving the facility.

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: 04/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2021
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-20201228095111
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: 515002765
VISIT DATE: 04/16/2021
NARRATIVE
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2) Staff not meeting resident's hygiene needs.

Based on statements obtained, LPA determined that there are insufficient statements. Staff interviewed stated that residents receive at least two showers a week; more if needed. Statements from residents interviewed confirmed this and confirms that they are receiving shower services. Facility has a designated staff who only provides shower services.

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 a copy of report along with appeal rights were given. LPA requested for a signed copy to be sent via e-mail/fax.

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

DATE: 04/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 25-AS-20201228095111
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: 515002765
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/16/2021
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: 04/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5