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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 515002765
Report Date: 04/24/2023
Date Signed: 04/24/2023 11:06:59 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/03/2023 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 25-AS-20230103141558
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
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Ivy GarnerTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Facility not communicating with responsible party
INVESTIGATION FINDINGS:
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LPA Hiratsuka, conducted the investigation into the allegation above.

LPA interviewed staff and the complainant. Administrator Assistant Ivy Garner stated she did not notify the responsible party of the missing item because she thought it was communicated to the responsible party by another family member of the resident in question. Facility had already contacted the doctor to make adjustments to the resident's dietary needs.

Based on the above, the allegation is substantiated.

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
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/03/2023 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 25-AS-20230103141558

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
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:TIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Facility staff did not safeguard resident's personal property.
Facility staff not following resident's care plan
INVESTIGATION FINDINGS:
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LPA Hiratsuka, conducted the investigation into the allegations above.

LPA received a copy of inventory lists of the resident's personal property and the care plan. The personal property lists did not mention the resident had dentures. LPA interviewed staff and they acknowledged the resident had dentures, but there is nothing in writing. The care plan did not mention the resident required dentures. Staff stated the resident required assistance putting in the dentures but was able to take them out and did take them out without staff present. Complainant stated resident was not capable of taking the dentures out.

Due to the information gathered, LPA cannot determine the Facility staff did not safeguard resident's personal property, and Facility staff not following resident's care plan. LPA finds allegation to be unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 25-AS-20230103141558
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
CCR
87468.1(a)(8)
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Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations,
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By 05/24/2023, the licensee shall submit in writing a communication plan to ensure responsible parties are notified regarding resident personal belongings going missing.
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as appropriate to their needs. This requirement is not met as evidenced by: Based on LPA's interviews the facility did not communicate the missing item to the responsible party. 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
LIC9099 (FAS) - (06/04)
Page: 2 of 3