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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002765
Report Date: 04/26/2022
Date Signed: 05/02/2022 07:27:48 AM

Document Has Been Signed on 05/02/2022 07:27 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:
04/26/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:IVY GARNERTIME COMPLETED:
02:00 PM
NARRATIVE
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During the investigation of Complaint #25-AS-20211011102847, a deficiency was noted and shall be cited on this LIC 809 document.

Donna Gurriere, Licensing Program Analyst was in contact and met with Ivy Garner, Assistant Administrator.

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.



continued
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: EMERALD OAKS
FACILITY NUMBER: 515002765
VISIT DATE: 04/26/2022
NARRATIVE
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During the visit to investigate residents that were incontinent with bladder issues, it was noted that there was an odor of urine in the hallway. The assistant administrator reported that they had a resident (Resident 1) residing in the facility that had incontinent issues and that when she stood up, she would not have control over her bladder, and she would wet on the carpet. The assistant administrator reported that the facility was in the process of changing out the carpet in the resident’s room.

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.



continued
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 05/02/2022 07:27 AM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Donna Gurriere On 04/25/2022 at 02:10 PM
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: 04/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
05/17/2022
Section Cited
CCR
87625(b)(3)

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Managed Incontinence - In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.
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The Assistant Administrator agrees to develop a plan for the incontinent resident to ensure that she is clean and dry. In addition, the Assistant Administrator agrees to have the carpets cleaned, removed and replaced.
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LPA witnessed the facility smelling of urine. The licensee did not ensure that the facility remains free of odors from incontinent residents. This poses a potential 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: 04/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2022


LIC809 (FAS) - (06/04)
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