<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002765
Report Date: 08/31/2021
Date Signed: 08/31/2021 11:12:13 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
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: 59DATE:
08/31/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:IVY GARNERTIME COMPLETED:
11:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Donna Gurriere, Licensing Program Analyst (LPA) arrived at the facility unannounced to conduct a case management visit regarding an incident.

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: Surgical mask. Additionally, LPA Gurriere was screened by administrator/staff person upon entering the facility.

On 05/04/21 it was reported that a resident (Resident 1) had an unwitnessed fall and was found laying on the ground in his room. The resident suffered a head injury and a humeral fracture. The resident was transported to the hospital. Later that day, the resident was returned to the facility. The resident was advised to not use the restroom unless he had supervision. Resident was placed on hospice and then passed away approximately one month later.

On 05/16/21 it was reported that a resident (Resident 2) had an unwitnessed fall and was found on the floor in his room. The resident had a laceration on the back of his head. The resident was sent to the hospital and returned later on the same day. The resident did not need sutures and is doing well. The resident is currently on 15 minute checks.

An exit interview was conducted, and a copy of the report was given to the administrator. No deficiencies cited.
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
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 1