515002765-5-2-2022-25-AS-KHOS-CE3HV7-20220503063124

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 515002765
Report Date: 04/26/2022
Date Signed: 05/02/2022 07:30:15 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
10/11/2021 and conducted by Evaluator Donna Gurriere

COMPLAINT CONTROL NUMBER: 25-AS-20211011102847

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:	04/26/2022
		UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	IVY GARNER		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff not providing accurate dosage of medication to a resident.
Unqualified staff are administering medication to residents.
Residents diapers are not changed in a timely manner resulting in a rash.
Staff are not responding to residents call button in a timely manner.
Resident's belongings were stolen.
Staff are not providing food to a residenet in a timely manner.
Staff are not providing adequate food service for a resident.
Staff are not providing residents with food of good quality.

INVESTIGATION FINDINGS:

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Donna Gurriere, Licensing Program Analyst was in contact and met with Ivy Garner, Assistant Administrator, in regards to the above mentioned allegations.

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

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: 04/26/2022

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.

LIC9099 (FAS) - (06/04)

Page: 1 of 6

Control Number 25-AS-20211011102847

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: 04/26/2022

NARRATIVE

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Staff are not providing an accurate dosage of medication to a resident.

During the interview process, the assistant administrator and four staff persons were interviewed. The resident (Resident 1) was not interviewed, as she is no longer residing at the facility. Documents were collected which included Hospice Records, Physician’s Report, Admission Agreement and Pre-Placement Appraisal.

Staff persons stated that they were not aware of an inaccurate dosage of medication that was given to a resident (Resident 1). It was reported that the resident was on hospice and not only were the med technicians ensuring that the medication was given correctly, it was reviewed by the hospice nurse also. The resident has since moved, and her medications could not be reviewed; however, during the process of this investigation, a site visit was conducted, and three residents were randomly selected for medication review. Medications were present and were in order, as required.

It could not be proven that Staff are not providing an accurate dosage of medication to a resident. 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. No deficiencies cited.

Unqualified staff are administering medication to residents.

During the interview process, the assistant administrator and four staff persons were interviewed. In addition, documents were collected which included Hospice Records, Physician’s Report, Admission Agreement, Pre-Placement Appraisal and Relias Computer Training Records.

continued

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

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 25-AS-20211011102847

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: 04/26/2022

NARRATIVE

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Required Training for staff hired after 01/01/16 includes: Cultural Competency, Personal Care Services; Physical Limitations and Needs of the Elderly; Residents’ Rights; Dementia Care; Building and Fire Safety and Appropriate Response to Emergencies; Antipsychotic and Psychotropic Medications; Policies and Procedures Regarding Medications; and Postural Supports, Restricted Health Conditions and Hospice Care.

It was reported and verified that staff persons are trained through Relias Online Training and then provided training by shadowing a more experienced staff person for the required 16-hour initial training. In addition, transcripts for three employees were reviewed to indicate that they had the appropriate training, in administering medications to residents.

It could not be proven that the Unqualified staff are administering medication to residents. 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. No deficiencies cited.

A resident’s diapers were not changed in a timely manner which resulted in a rash.

During the interview process, the assistant administrator and four staff persons were interviewed. The resident (Resident 1) has moved and was not interviewed. In addition, documents were collected which included Hospice Records, Physician’s Report, Admission Agreement and Pre-Placement Appraisal.

Hospice notes indicated that Resident 1 was able to make her basic needs known to the staff persons, which was supported by staff statements during the interview process. Peri care was recommended by the hospice nurse to include changing incontinent care products and to ensure that the resident did not suffer from a skin breakdown. A review of the hospice notes indicated that the resident did not have a rash, wound, or ulcer/bed sores. In addition, staff persons follow a “Tier Level System” with resident names that indicate which residents are incontinent and need assistance with being clean and dry with their incontinent products.

continued

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

LIC9099 (FAS) - (06/04)

Page: 6 of 6

Control Number 25-AS-20211011102847

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: 04/26/2022

NARRATIVE

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It could not be proven that A resident’s diapers were not changed in a timely manner, which resulted in a rash. 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. No deficiencies cited.

Staff are not responding to residents’ call buttons in a timely manner.

During the interview process, the assistant administrator and four staff persons were interviewed. The resident (Resident 1) has moved and was not interviewed. In addition, documents were collected which included Hospice Records, Physician’s Report, Admission Agreement, Pre-Placement Appraisal and Inservice Training on Call Bell Policy and Procedures. Staff persons signed off that they were present for the training.

Staff persons were interviewed, and they reported that they try to respond to the call buttons within a five-minute period. The training that was provided to the staff stated that if the staff person on call for the resident could not attend the resident within the five-minutes, then it is their responsibility to radio another staff person to assist. Overall, it was reported that staff respond to the residents in a timely manner.

It could not be proven that Staff are not responding to residents’ call buttons in a timely manner. 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. No deficiencies cited.

continued

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

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 25-AS-20211011102847

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: 04/26/2022

NARRATIVE

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A resident’s belongings were stolen.

During the interview process, the assistant administrator, and four staff persons were interviewed. In addition, the Ombudsman advised that she met with the resident to discuss the resident’s Property and Valuables List. The resident (Resident 1) has moved and was not interviewed. In addition, documents were collected which included Hospice Records, Physician’s Report, Admission Agreement, Pre-Placement Appraisal and Personal Property and Valuables List for the resident.

It was reported and documents reviewed, that the assistant administrator along with the Ombudsman reviewed the resident’s Personal Property and Valuables List (two lists) with the resident. The assistant administrator and the Ombudsman could not determine or substantiate any of the resident’s items missing.

It could not be proven that A resident’s belongings were stolen. 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. No deficiencies cited.

continued

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

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 25-AS-20211011102847

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: 04/26/2022

NARRATIVE

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Staff not providing food to a resident in a timely manner.
Staff are not providing adequate food service to a resident.
Staff are not providing residents with food of good quality.

During the interview process, the assistant administrator, four staff persons, two cooks and three residents were interviewed. The resident (Resident 1) has moved and was not interviewed.

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. An unannounced 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, that there was adequate food and that the food was of good quality.

It could not be proven that Staff are not providing food to a resident in a timely manner, Staff are not providing adequate food service to a resident and Staff are not providing residents with food of good quality. 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.

During the investigation of this Complaint #25-AS-20211011102847, a deficiency was noted and shall be cited on a separate Facility Evaluation Report (LIC 809).

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

LIC9099 (FAS) - (06/04)

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