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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002765
Report Date: 04/12/2022
Date Signed: 04/18/2022 08:03:16 AM

Document Has Been Signed on 04/18/2022 08:03 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
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: 65DATE:
04/12/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:IVY GARNERTIME COMPLETED:
12:45 PM
NARRATIVE
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During the investigation of Complaint #25-AS-20210722143123, dated 07/22/21 a deficiency was noted and shall be cited on this LIC 809 document. The initial allegation was that a Resident was left in bed in her own urine.

Donna Gurriere, Licensing Program Analyst was in contact and met with Ivy Garner, Assistant Administrator. It was alleged that a resident (Resident 1) is being left in her bed in her own urine.

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.

Although it was not indicated that the resident was left in bed in her own urine, the staff are required to follow a bowel and bladder program developed by a skilled professional. The staff have indicated that they followed a schedule; however, the staff have not been trained by a skilled professional, as required.

Based on the evidence obtained, the preponderance of evidence standard has been met; therefore, the deficiency is found to be Substantiated. California Code of Regulations (Title 22) is being cited on the attached LIC 809D. Appeal rights were provided and the exit interview conducted.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2022
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 04/18/2022 08:03 AM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Donna Gurriere On 04/11/2022 at 10:13 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: EMERALD OAKS
FACILITY NUMBER: 515002765

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
04/13/2022
Section Cited
CCR
87625(b)(5)

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87625 (b)(5) Managed Incontinence - In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: Ensuring that the appropriately skilled professional developing the bowel and/or bladder program provide training to facility staff responsible for implementation of the program. The licensee did not ensure that
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The Assistant Administrator agrees to enroll staff persons in training with a skilled professional in regard to Managed Incontinence. Assistant Administrator shall have staff enrolled by 04/13/22 and shall submit a list of staff persons names that are being trained. Assistant Administrator agrees to submit the date of training.
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training was provided by a skilled professional for staff that are providing incontinence care to residents. This poses an immediate safety risk to residents in care.
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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:Anthony Perez
LICENSING EVALUATOR NAME:Donna Gurriere
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022


LIC809 (FAS) - (06/04)
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