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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002765
Report Date: 04/24/2023
Date Signed: 04/24/2023 11:05:12 AM


Document Has Been Signed on 04/24/2023 11:05 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:EMERALD OAKSFACILITY NUMBER:
515002765
ADMINISTRATOR:BAINS, GURPRITFACILITY TYPE:
740
ADDRESS:2290 FORREST LANETELEPHONE:
(530) 751-0511
CITY:YUBA CITYSTATE: CAZIP CODE:
95993
CAPACITY:116CENSUS: DATE:
04/24/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Ivy GarnerTIME COMPLETED:
11:15 AM
NARRATIVE
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LPA Hiratsuka, conducted this case management in response to a complaint investigation. While investigating complaint control number 25-AS-20230103141558, LPA learned a resident wore dentures. LPA reviewed the resident's written plan of care and annual assessments. Both did not mention the resident wore dentures. The resident's physician's report stated the resident wears dentures. The documentation also did not state the resident's physical and mental capabilities to wearing the dentures because the resident had dementia. The regulations requires that assessment are to be done annual and while they did the assessment annually, it did not address the dentures. The assessment and written plan of care just stated the resident required assistance eating.


Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code. Failure to correct shall result in civil penalties. appeal rights left.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 04/24/2023 11:05 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833


FACILITY NAME: EMERALD OAKS
FACILITY NUMBER: 515002765

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/24/2023
Section Cited

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Care of Persons with Dementia. Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least
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By 05/24/2023, the facility shall ensure all written plans of care and assessments are complete. Licensee shall submit in writing how they shall ensure all are complete.
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annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by:Based on LPAs interivews everyone knew resident required dentures but it was not written down. This does not pose an immediate risk to residents.
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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: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2