019201167-12-18-2025-15-AS-YFLS-DPLSYF-20251222131728

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201167
Report Date: 09/19/2025
Date Signed: 12/18/2025 08:08:14 AM

Unsubstantiated

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
04/25/2025 and conducted by Evaluator Ardalan Gharachorloo

COMPLAINT CONTROL NUMBER: 15-AS-20250425125708

FACILITY NAME:	EMERALD VALLEY		FACILITY NUMBER:	019201167
ADMINISTRATOR:	ESPINOZA, MARISSA K		FACILITY TYPE:	740
ADDRESS:	7601 AMADOR VALLEY BLVD		TELEPHONE:	(925) 361-0913
CITY:	DUBLIN	STATE: CA	ZIP CODE:	94568
CAPACITY:	80	CENSUS: 76	DATE:	09/19/2025
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Janelle Douglas, Executive Director		TIME COMPLETED:	11:50 AM

ALLEGATION(S):

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Staff neglect led to resident's injury
Staff did not refund resident according to the residen's Admission Agreement
Staff mismanaged resident medication

INVESTIGATION FINDINGS:

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This is an amended report.On 09/19/2025 at 9:30 AM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to deliver findings regarding the allegations listed above. LPA met with Interim Executive Director, Vercina Curley and explained the purpose of the visit.

During the course of the investigation, LPA interviewed W1, four staff members (S1–S4), reviewed records for R1, R2, and R3, including but not limited to admission agreements,care plans, Medication Administration Records (MARs), physician reports, progress notes, staff roster and staff schedules.

Allegation: Staff neglect led to resident's injury - Unsubstantiated

Review of R1's file revealed that Staff at the facility reevaluated R1 after they saw pattern of R1 falling. S1 reported that "the decision was made to change R1s footwear to shoes that were better fit to prevent falls".

***CONTINUE ON 9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Ardalan Gharachorloo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2025

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-20250425125708

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: 09/19/2025

NARRATIVE

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***CONTINUE FROM 9099***

S1 also reported that R1 was encouraged to use pendent for assistance in daily activities in addition to regular check-ins. S3 stated that he always went to R1s room to offer assistance and "passed on notes to the next caregiver on shift". LPA reviewed communication log, check-in schedule, and internal caregiver notes. LPA reviewed staff schedule for the month of March and April. On 4/14, S3 stated that he "found R1 on the floor outside of his room with blood coming from R1's head. S1 stated that "911 was called by the med tech, W1 was notified, and R1 was taken to the hospital immediately". W1 stated that she is unable to provide hospital records and pictures. Review of R1's care plan and staff assignment sheet revealed that R1 was on a total assist with activities of daily living.

Allegation: Staff did not refund resident according to the resident’s Admission Agreement- Unsubstantiated

Review of R1s payer summary revealed that W1 paid the facility $16998.38 on 04/08/2025. On 04/21 W1 was refunded 10081.67 which included 5081.76 for the the part of the month that R1 was not residing at the facility. The summary also showed that R1 was refunded one time move in fee of $5000. W1 stated that she did receive 10081.67 from the facility. S4 stated that "what we have in the admission agreement is what we follow". LPA reviewed the ledger and the admission agreement for R1.

Allegation: Staff mismanaged resident medication - Unsubstantiated

Review of R1 record revealed that R1 was at the facility for 18 days. W1 stated that she received a call regarding missing medication. No staff member at the facility could verify that called her regarding missing medication. S2 stated that only 1 over the counter medication was missing. S2 further stated that W1 "called and mentioned that she will bring the over the counter medication to the facility". LPA checked the MAR for R1. No missing medication was marked on R1's MAR. LPA also reviewed a sample of resident's (R2,R3) medications. There was no missing medications reported on R2's and R3's MARs.

***CONTINUE ON 9099C***

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Ardalan Gharachorloo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2025

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20250425125708

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: 09/19/2025

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 9099C* This agency has investigated the above allegations. We have found that the allegations were unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted, a copy of this report provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Ardalan Gharachorloo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2025

LIC9099 (FAS) - (06/04)

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