515002765-4-18-2022-25-AS-LMUZ-CDNQ3Q-20220420114906

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 515002765
Report Date: 04/12/2022
Date Signed: 04/18/2022 08:01:48 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/21/2021 and conducted by Evaluator Donna Gurriere

COMPLAINT CONTROL NUMBER: 25-AS-20210621084647

FACILITY NAME:	EMERALD OAKS		FACILITY NUMBER:	515002765
ADMINISTRATOR:	BAINS, GURPRIT		FACILITY TYPE:	740
ADDRESS:	2290 FORREST LANE		TELEPHONE:	(530) 751-0511
CITY:	YUBA CITY	STATE: CA	ZIP CODE:	95993
CAPACITY:	116	CENSUS: 65	DATE:	04/12/2022
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	IVY GARNER		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Residents do not receive food in a timely manner
Staff serve residents cold food.
Staff do not follow protocol to prevent the spread of illness.
Facility has bed bugs.

INVESTIGATION FINDINGS:

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Donna Gurriere, Licensing Program Analyst was in contact and met with Ivy Garner, Assistant Administrator. It was alleged that Residents do not receive food in a timely manner, Staff serve residents cold food, Staff do not follow protocol to prevent the spread of illness and Facility has bed bugs.

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.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (530) 895-5033
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.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 25-AS-20210621084647

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/12/2022

NARRATIVE

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Residents do not receive food in a timely manner and Staff serve residents cold food.

During the investigation process, the administrative assistant, five staff persons and five residents were interviewed. In addition, the facility’s food service policy and menu were reviewed.
It was reported that meals are served at 8:00 a.m., 12:00 p.m., and 5:00 p.m. and that snacks are provided twice a day. It was stated that residents either eat in the dining room or in their rooms. A walk through of the kitchen was conducted and the lunch menu consisted of Salisbury steak, green beans, potatoes with gravy, rice crispy treats and/or sugar free Jell-O. The cook advised that she serves 50 residents in the dining area and 11-15 residents are given tray service in their rooms. The cook stated that the care providers and the med technicians assist when serving the residents, as needed. Dinner was also in preparation and was observed to be lemon chicken, vegetables and rolls. The food being served appeared to be of good nutrition and was being served hot. A menu was observed in the kitchen and the cook was following the daily menu. During the interview process, overall, it was reported that the residents do receive their food in a timely manner and that residents are not served cold food.

It could not be proven that Residents do not receive food in a timely manner and that
Staff serve residents cold food. Although the allegations may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are Unsubstantiated.

continued

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (530) 895-5033
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

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 25-AS-20210621084647

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/12/2022

NARRATIVE

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Staff do not follow protocol to prevent the spread of illness.

During the investigation process, the administrative assistant, four staff persons and two residents were interviewed. In addition, supportive documents that were provided included a Physician Reports, Admission Agreements, Resident Appraisal and laboratory results.

It was reported that two residents (Resident 1 and Resident 2) may have had Clostridium Difficile (C-Diff). During the interview process, it was stated that during the month of January 2021 it was suspected that the residents had C-Diff; therefore, the staff set up a Personal Protective Equipment (PPE) station near the residents’ rooms for precautions. The facility provided copies of the C-Diff results which indicated that the residents were negative.

It could not be proven that Staff do not follow protocol to prevent the spread of illness.
Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated.

Facility has bed bugs.

During the investigation process, the administrative assistant, four staff persons and two residents were interviewed. In addition, invoices were received and reviewed from the pest control company.

continued

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (530) 895-5033
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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 25-AS-20210621084647

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/12/2022

NARRATIVE

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Prior to the complaint and during the month of June 2021, a pest control company was treating the facility for bed bugs. In addition, when the facility noticed that they had bed bugs, they notified the licensing agency via incident report. The administrator assistant reported that the pest control company continues to come to the facility on a monthly basis and also checks specifically for bed bugs. Copies of invoices from the pest control company were provided and verified for the months of January through June 2021.

Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (530) 895-5033
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

LIC9099 (FAS) - (06/04)

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