515002765-5-16-2022-25-AS-KHOS-CEGN7N-20220516101300

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 515002765
Report Date: 05/03/2022
Date Signed: 05/16/2022 09:47:00 AM

Unsubstantiated

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
10/27/2021 and conducted by Evaluator Donna Gurriere

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20211027151708

FACILITY NAME:	EMERALD OAKS		FACILITY NUMBER:	515002765
ADMINISTRATOR:	BAINS, GURPRIT		FACILITY TYPE:	740
ADDRESS:	2290 FORREST LANE		TELEPHONE:	(530) 751-0511
CITY:	YUBA CITY	STATE: CA	ZIP CODE:	95993
CAPACITY:	116	CENSUS: 65	DATE:	05/03/2022
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	IVY GARNER		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

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A resident was left in a soiled diaper for 2.5 days.
Staff are not giving a resident prescribed medication for a rash.

INVESTIGATION FINDINGS:

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Donna Gurriere, Licensing Program Analyst was in contact and met with Ivy Garner, Assistant Administrator. It was alleged that A resident was left in a soiled diaper for 2.5 days and that Staff are not giving a resident prescribed medication for a rash.

LPA Gurriere completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID 19 infection to affirm no COVID-19 related symptoms. The administrator/staff person was contacted to complete a facility risk assessment. LPA Gurriere ensured that hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. Additionally, LPA Gurriere was screened by a staff person upon entering the facility.

continued

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022

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 25-AS-20211027151708

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: 05/03/2022

NARRATIVE

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A resident was left in a soiled diaper for 2.5 days.

During the investigation process the assistant administrator and seven staff persons were interviewed. In addition, an attempted interview was conducted with the resident (Resident 1); however, he was not able to respond to the asked questions due to his diagnosis. Documentation was received and reviewed to include the Physician’s Report, Admission Agreement, Appraisal and Needs Plan, Medication Administrative Record (MARs) and a doctor’s order from the Veteran’s Affairs (VA). In addition, three residents’ medications were reviewed.

It was reported by all staff persons interviewed that they were not aware that the resident was left in a soiled diaper for 2.5 days. It was reported that the resident was difficult in that he was aggressive and combative, and at times would refuse to be changed by the staff persons. A doctor’s order was obtained from the Veteran’s Affairs (VA) Nurse Practitioner which stated, “The public guardian should be notified, and the patient should be sent to local emergency room for evaluation if he refuses perineal or incontinence care for any period of time exceeding 8 hours.” Staff reported that the resident had his medications changed and that he is now more amenable to having his briefs changed.

It could not be proven that A resident was left in a soiled diaper for 2.5 days. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated.

continued

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20211027151708

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: 05/03/2022

NARRATIVE

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During the investigation process the assistant administrator and seven staff persons were interviewed. In addition, an attempted interview was conducted with the resident (Resident 1); however, he was not able to respond to the asked questions due to his diagnosis. Documentation was received and reviewed to include the Physician’s Report, Admission Agreement, Appraisal and Needs Plan, Medication Administrative Record (MARs) and a doctor’s order were reviewed. In addition, three residents’ medications were reviewed.

It was reported by all staff persons that they were giving the resident his prescribed medication (Zinc Oxide) for a rash. It was reported that when the resident would refuse to be changed, the staff persons could not apply the cream. A review of cream medications for three of the residents were observed and their medications were in compliance.

It could not be proven that Staff are not giving a resident prescribed medication for a rash. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022

LIC9099 (FAS) - (06/04)

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