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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002765
Report Date: 05/18/2022
Date Signed: 05/18/2022 11:52:52 AM


Document Has Been Signed on 05/18/2022 11:52 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:
05/18/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sarah Thomas, RSD and Ivy Garner, ED in TrainingTIME COMPLETED:
12:00 PM
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
Licensing Program Analysts (LPA) Mai Thao and IB Investigator Melissa Bennett arrived at the facility to conduct an unannounced case management visit. LPA met with Sarah Thomas, Residential Service Director and Ivy Garner, ED in Training. LPA explained the purpose of the visit. Prior to initiating the case management visit, LPA and IB Investigator completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA and IB Investigator ensured they wash their hands before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 and surgical mask. In addition, Staff screened LPA and IB Investigator prior to entering the facility.

It was reported to Licensing on January 6, 2022 that on 12/25/2022, Resident 1 (R!) had an unwitnessed fall, was sent out to the Emergency Room (ER), and sustained a fracture.

During today's visit, LPA, IB investigator, RSD and ED in Training discussed the incident. Through record review, it was observed that R1 was under the care of Hospice. RSD and ED in Training stated that resident was on a precaution 2 hour checks that were documented on logs. RSD and ED stated that R1 is able to use the bathroom independently and may require stand-by assist if needed. LPA and IB investigator reviewed R1 LIC 602 Physician's Report and Care Plan. LPA did not observe R1 activities of daily living (ADLs) being address. LPA advised facility on updating care plans to meet changes in condition. LPA observed that R1 had a Hospice Care Plan on file. LPA observed on facility documentation that staff last checked on resident at 6:55pm and at 7pm staff heard resident calling for help. The facility immediately went to the resident, assess the incident, and contacted 911.

No citations were observed during this visit. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Mai ThaoTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2022
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 1