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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201167
Report Date: 07/07/2025
Date Signed: 07/07/2025 01:26:43 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/03/2025 and conducted by Evaluator Ardalan Gharachorloo
COMPLAINT CONTROL NUMBER: 15-AS-20250403102608
FACILITY NAME:EMERALD VALLEYFACILITY NUMBER:
019201167
ADMINISTRATOR:ESPINOZA, MARISSA KFACILITY TYPE:
740
ADDRESS:7601 AMADOR VALLEY BLVDTELEPHONE:
(925) 361-0913
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY:80CENSUS: 80DATE:
07/07/2025
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Marissa Espinoza, Executive DirectorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not meeting the resident's medical needs.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 07/07/2025 at 11:15 AM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to deliver findings regarding the allegation listed above. LPA met with Executive Director, Marissa Espinoza and explained the purpose of the visit.

During the course of the investigation, LPA interviewed W1, Five staff members (S1–S5), three residents, and reviewed records for R1, R2, and R3, including but not limited to care plans, Medication Administration Records (MARs), physician reports, progress notes, and staff schedules. LPA also reviewed W1's email correspondence and video footage of R1’s room provided by W1.

Allegation: Staff are not meeting the resident's medical needs — Substantiated

***CONTINUE ON 9099C***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Ardalan Gharachorloo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2025
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 3
Control Number 15-AS-20250403102608
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: EMERALD VALLEY
FACILITY NUMBER: 019201167
VISIT DATE: 07/07/2025
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
26
27
28
29
30
31
32
***CONTINUE FROM 9099***

LPA reviewed email correspondence from W1 documenting multiple attempts since January 2025 to address concerns regarding R1’s catheter care. W1 stated she observed through a camera that the catheter bag was often full and discolored. On 03/11/2025, R1 was taken to the ER due to lack of urine output and diagnosed with a severely distended bladder. Per W1’s email dated 03/12/2025, the hospital removed “a large amount of urine” from R1 and recommended changes to prevent recurrence. In another email dated 03/28/2025, W1 shared that her home health nurse discovered the catheter had become disconnected, with urine draining into R1’s clothing, which was wet upon her arrival.

Interviews with S2,S3 and S5 revealed that while staff were aware of the catheter, monitoring duties were not clearly assigned during overnight shifts. S5 noted that catheter issues were often identified by home health, not staff. LPA reviewed progress notes and MARs and did not find consistent documentation of catheter care checks. W1 expressed concern that staff contacted her while she was out of the country instead of the 24/7 home health service listed in R1’s file. Based on W1’s evidence, lack of documentation, and interviews confirming inconsistent practices, this allegation is substantiated.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.




Exit interview conducted, a copy of this report and appeal rights provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Ardalan Gharachorloo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20250403102608
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: EMERALD VALLEY
FACILITY NUMBER: 019201167
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/08/2025
Section Cited
CCR
87623(b)(2)(A)
1
2
3
4
5
6
7
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:(2) Ensuring that the bag and tubing are changed by...(A)The bag may be emptied by facility staff who receive instruction from an appropriately skilled professional.
1
2
3
4
5
6
7
The licensee must ensure that trained staff are assigned and available to monitor and manage R1's catheter as required by the care plan. An attestation letter and plan of monitoring by ED to be submitted to CCL by 7/8/25
8
9
10
11
12
13
14
Based on interviews, record review, and documentation provided by W1, the facility did not ensure that person trained to provide catheter care was available to monitor and manage R1's foley catheter in accordance with the resident's care plan.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Ardalan Gharachorloo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3