Inspection Reports for Emerald Oaks Inc

This unannounced case management visit was conducted in response to a death report submitted by the facility.

The Licensing Program Analyst obtained some documentation from the facility. No deficiencies were cited, but the matter requires further investigation.

This visit was conducted as a follow-up for complaint #59-AS-20250428114131 to interview staff regarding a resident.

No deficiencies were cited during this follow-up visit.

Follow-up visit related to complaint #59-AS-20250428114131; no deficiencies cited.

This unannounced case management visit was conducted in response to a resident who left the facility without being noticed on July 19, 2025, and was not noticed gone until the early morning of July 20, 2025.

The facility failed to monitor residents properly, resulting in a resident leaving the facility unnoticed for multiple hours, which posed an immediate health and safety risk. Elopement drills and monitoring procedures are being implemented to address this issue.

Licensing Program Analysts conducted a visit to deliver two amended complaint reports that were initially delivered on 05/01/2025 and 06/19/2025.

No deficiencies were cited during this visit.

The visit was an unannounced complaint investigation conducted in response to allegations received on 2025-04-28 regarding oral hygiene care, safeguarding personal belongings, and ensuring clean clothing for a resident.

The investigation found that the resident has dementia and it was difficult to determine the resident's ability to manage dentures and oral hygiene. Staff reported assisting with denture cleaning and observed clean clothes in the resident's room. The resident has the right to wear what they want, and staff need to work with the resident to ensure clean clothing. The allegations were found to be unsubstantiated with no deficiencies cited.

The complaint involved allegations that facility staff did not provide oral hygiene care, did not safeguard the resident's personal belongings, and did not ensure the resident had clean clothing. The investigation concluded the allegations were unsubstantiated due to insufficient evidence to prove violations.

The visit was an unannounced complaint investigation triggered by allegations received on 2025-02-24 regarding staff response to resident alerts, adequacy of care and supervision, and staff training on transfers and lifts.

The investigation found the allegations unsubstantiated or unfounded. There was insufficient evidence to prove staff failed to respond timely to resident alerts or provide adequate care. Staff training on transfers and lifts met Title 22 requirements. No deficiencies were cited.

The complaint involved multiple allegations: staff did not timely respond to resident alerts, did not provide adequate care and supervision, and were not properly trained on transfers and lifts. The investigation concluded the first two allegations were unsubstantiated due to lack of evidence, and the third was unfounded as staff had required training.

This was an unannounced annual inspection visit conducted as a required one-year inspection to evaluate the facility's compliance with licensing regulations.

The licensing program analyst toured the facility and reviewed resident and staff records. No issues of concern or deficiencies were observed during the inspection.

The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2024-01-24 regarding staff mistreating residents and residents not being allowed to use the phone.

The investigation found the allegation of staff mistreating residents to be unsubstantiated due to conflicting witness accounts and lack of proof. The allegation that residents were not allowed to use the phone was found to be unfounded, as residents had access to telephones and no one was told they could not use them.

The complaint involved allegations of staff mistreating residents and residents not being allowed to use the phone. The mistreatment allegation was unsubstantiated, meaning there was not a preponderance of evidence to prove the violation occurred. The phone use allegation was unfounded, meaning it was false or without reasonable basis.

This was an unannounced annual inspection visit conducted as a required one-year evaluation of the facility.

The inspection included review of resident records and staff files, observation of facility layout and infection control practices, and discussion of multiple topics. No deficiencies were cited, but updates to certain documents must be submitted within 30 days.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-01-03 regarding the facility not communicating with the responsible party and other allegations related to resident care and property.

The investigation substantiated that the facility failed to notify the responsible party about a missing item, although the facility had contacted the doctor to adjust the resident's dietary needs. Another allegation regarding safeguarding resident's personal property and following the care plan was found unsubstantiated due to insufficient evidence.

The complaint was substantiated regarding failure to communicate with the responsible party about a missing item. Another complaint about safeguarding resident's personal property and adherence to the care plan was unsubstantiated due to lack of evidence.

The visit was conducted as a case management in response to a complaint investigation regarding a resident who wore dentures that were not documented in the resident's plan of care or annual assessments.

The investigation found that the resident's written plan of care and annual assessments did not mention the use of dentures, nor did they address the resident's physical and mental capabilities related to wearing dentures despite the resident having dementia. This was a deficiency cited under Title 22 Regulations and the California Health and Safety Code.

The visit was triggered by complaint control number 25-AS-20230103141558. The complaint was substantiated as the resident wore dentures that were not documented in care plans or assessments.

This was an unannounced annual inspection visit required by the licensing authority to evaluate facility compliance.

The inspection found no deficiencies. Several resident and staff files were reviewed, and multiple topics were discussed. Some documents were required to be updated and submitted within 30 days.

The visit was a case management visit to advise the facility administrator about the proper use of a Hoyer Lift following a complaint visit on 04/12/22 regarding staff use of the lift to transport a resident from bed to bathroom.

The investigation determined that the Hoyer Lift should only be used to transfer a resident from bed to wheelchair or bedside commode, not for transfers from one room to another. The administrator acknowledged understanding the proper use. No deficiencies were cited.

The visit was related to a complaint received about improper use of a Hoyer Lift during a resident transfer on 04/12/22. The complaint was investigated and found to be a misuse of the lift, but no deficiencies were cited.

The visit was an unannounced case management investigation triggered by a reported incident involving Resident 1 who had an unwitnessed fall on 12/25/2022 resulting in a fracture and emergency room visit.

The investigation found that Resident 1 was under Hospice care with documented 2-hour precaution checks. Staff last checked on the resident shortly before the incident and responded immediately by assessing the resident and contacting 911. No citations were issued during this visit.

The complaint involved an unwitnessed fall of Resident 1 on 12/25/2022 resulting in a fracture. The facility had precautions in place and documented checks. The complaint was investigated with no citations issued.

An unannounced complaint investigation was conducted following allegations that a resident was left in a soiled diaper for 2.5 days and that staff were not giving a resident prescribed medication for a rash.

The investigation included interviews with staff and review of documentation. It was found that there was no preponderance of evidence to prove the allegations, and both claims were unsubstantiated.

The complaint alleged that a resident was left in a soiled diaper for 2.5 days and that staff were not administering prescribed medication for a rash. After investigation, including interviews and document review, the allegations were found unsubstantiated due to lack of evidence.

An unannounced complaint investigation visit was conducted in response to multiple allegations received on 10/11/2021 regarding medication administration, resident care, food service, and resident property issues at Emerald Oaks facility.

The investigation found no preponderance of evidence to substantiate any of the allegations, including inaccurate medication dosage, unqualified staff administering medication, untimely diaper changes causing rash, delayed response to call buttons, stolen resident belongings, and inadequate food service. All findings were unsubstantiated and no deficiencies were cited in this report.

The complaint investigation was unsubstantiated. Despite multiple allegations, including medication errors, staff qualifications, resident care, and food service issues, the evidence did not support the claims. The resident involved had moved and was not interviewed. Staff interviews and document reviews did not confirm violations.

The visit was conducted to investigate a complaint (#25-AS-20211011102847) regarding residents with incontinence and bladder issues.

The investigation found a substantiated deficiency related to the facility smelling of urine due to inadequate management of incontinent residents, posing a potential safety risk. The facility was in the process of changing the carpet in the affected resident's room.

The deficiency was substantiated based on the preponderance of evidence standard. The citation is related to the complaint #25-AS-20211011102847. Appeal rights were provided and the exit interview was conducted.

The inspection was an unannounced complaint investigation visit triggered by allegations 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 the facility has bed bugs.

The investigation included interviews with staff and residents, review of policies, menus, medical and pest control documentation. The findings concluded that there was insufficient evidence to substantiate the allegations, and all claims were determined to be unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included delayed food service, cold food, failure to follow illness prevention protocols, and presence of bed bugs. Evidence reviewed included interviews, facility policies, medical reports, and pest control invoices. No violations were proven.

The visit was an unannounced complaint investigation triggered by allegations that a resident was being transferred from bed to toilet in an unsafe manner and that a resident was left in bed in her own urine.

The investigation included interviews with staff and the resident, review of documentation, and observation of equipment use. It was found that there was no preponderance of evidence to prove the allegations, and both were unsubstantiated. However, staff had not been trained by a skilled professional on the bowel and bladder program as required, leading to a separate citation.

The complaint investigation was unsubstantiated for both allegations: unsafe transfer of a resident using a Hoyer Lift and a resident being left in bed in her own urine. The resident reported feeling safe during transfers, and staff followed an incontinence schedule. However, staff training on the bowel and bladder program was inadequate.

The visit was conducted as part of an investigation of Complaint #25-AS-20210722143123, alleging that a resident was left in bed in her own urine.

The investigation found that although it was not indicated that the resident was left in bed in her own urine, the staff failed to receive required training by a skilled professional on the bowel and bladder program, which was substantiated as a deficiency.

The complaint was substantiated based on the preponderance of evidence standard. The allegation was that a resident was left in bed in her own urine, but the deficiency cited was related to lack of staff training on the bowel and bladder program.

The inspection was an unannounced Required-1 Year Inspection focusing on the infection control domain to ensure health and safety compliance at the facility.

The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited as a result of the inspection.

The visit was an unannounced case management visit regarding an incident involving resident falls and injuries.

The Licensing Program Analyst conducted COVID-19 screening protocols and reviewed incidents of two unwitnessed resident falls resulting in injuries. No deficiencies were cited during the visit.

The inspection was an unannounced complaint investigation visit conducted due to a complaint received on 2020-12-28 regarding staff mismanaging a resident's medication and other allegations.

The investigation substantiated the allegation that staff mismanaged a resident's medication, specifically that medication was not properly logged into the facility's Centrally Stored Medication Log. Other allegations regarding a resident wandering away and staff not meeting hygiene needs were found to be unsubstantiated due to insufficient evidence.

The complaint investigation was substantiated for medication mismanagement but unsubstantiated for allegations that a resident wandered away and staff not meeting hygiene needs.