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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002765
Report Date: 10/19/2023
Date Signed: 10/19/2023 02:13:11 PM


Document Has Been Signed on 10/19/2023 02:13 PM - 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:EMERALD OAKSFACILITY NUMBER:
515002765
ADMINISTRATOR:BAINS, GURPRITFACILITY TYPE:
740
ADDRESS:2290 FORREST LANETELEPHONE:
(530) 490-1401
CITY:YUBA CITYSTATE: CAZIP CODE:
95993
CAPACITY:116CENSUS: 72DATE:
10/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Ivy Garner, Assistant AdministratorTIME COMPLETED:
02:20 PM
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LPA Hiratsuka, conducted this unannounced annual visit. LPA wore a surgical mask and observed all staff wearing surgical masks. LPA was also screened by the front desk.

The main entrance opens to the main hallway. The administration offices are to the right of the main entrance. This facility has a hallway on the left that leads to the kitchen, main dining room, and leads back to another hallway. There are two hallways on the right that are not connected to each other. The second hallway in the back that goes to the right leads to the activity area. There are three short hallways that lead off from the very back hallways with the ends leading to the outside. There are two outdoor areas and they are both enclosed. This facility has 59 resident rooms; three have full private bathrooms and the rest have half private bathrooms. There is a medication room to the right past the administration offices.

Multiple topics discussed.
Several resident records were reviewed
Several staff files were reviewed.

The following shall be updated and submitted to licensing within 30 days;
LIC 500- facility personnel or staff schedule
LIC 308- designation of administrative responsibility
LIC 610- emergency disaster plan


No deficiencies cited.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023
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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