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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201167
Report Date: 10/30/2025
Date Signed: 10/30/2025 11:33:38 AM

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
05/05/2025 and conducted by Evaluator Ardalan Gharachorloo
COMPLAINT CONTROL NUMBER: 15-AS-20250505113433
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: 78DATE:
10/30/2025
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Janelle Douglas, Executive Director TIME COMPLETED:
11:45 PM
ALLEGATION(S):
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Staff improperly restrained resident in care.
INVESTIGATION FINDINGS:
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On 10/30/2025 at 9:40 AM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to deliver findings in regard to the allegation above. LPA met with Janelle Douglas, Executive Director and explained the purpose of the visit.

During the course of the investigation, the Licensing Program Analyst (LPA) interviewed staff (S1–S3) and residents (R1–R3), and also interviewed a witness (W1). LPA toured the second-floor memory care unit and reviewed staff files for S1–S6. LPA also reviewed the facility’s internal investigation report, termination letters, and the incident report dated April 17, 2025.

Review of the facility’s internal investigation report, incident report dated April 17, 2025, and termination letters revealed that staff S4, S5, and S6 restrained a resident for an extended period of time.

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

DATE: 10/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025
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 4
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
05/05/2025 and conducted by Evaluator Ardalan Gharachorloo
COMPLAINT CONTROL NUMBER: 15-AS-20250505113433

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: 78DATE:
10/30/2025
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Janelle Douglas, Executive Director TIME COMPLETED:
11:45 PM
ALLEGATION(S):
1
2
3
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5
6
7
8
9
Staff member is under the influence while providing care and supervision to residents in care.
INVESTIGATION FINDINGS:
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13
On 10/30/2025 at 9:40 AM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to deliver findings in regard to the allegation above. LPA met with Janelle Douglas, Executive Director and explained the purpose of the visit.

During the course of the investigation, LPA interviewed 3 staff members, 3 residents ,and reviewed 3 staff records. Interviews with S1– S3, R1–R3, and W1 revealed no evidence that any staff member was under the influence while on duty. Review of available records and interviews did not show any indication of staff impairment or related incidents.

This agency has investigated the allegation above. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted, a copy of this report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Ardalan Gharachorloo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20250505113433
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: 10/30/2025
NARRATIVE
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***CONTINUE FROM 9099***

Interviews with S1–S3 also confirmed that S4, S5, and S6 restrained the resident while in the second-floor memory care unit. Review of the documents indicated that the resident remained restrained overnight, which led to disciplinary action and termination of the involved staff members.


Based on LPA's 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 and a copy of this report and appeals rights provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Ardalan Gharachorloo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20250505113433
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: 10/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/13/2025
Section Cited
CCR
87468.1(a)(3)
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Residents in all residential care facilities for the elderly shall have all of the following personal rights...(3)To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.

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Executive director to retrain all staff on resident personal rights. Proof of training, including agenda and staff sign-in sheet, will be submitted to CCL by POC date.
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Based on record review and staff interview, it was determined that staff (S4-S6) restrained a resident for an extended period of time while in the memory care unit. Review of staff records, termination letters confirmed the restraint occured, posing an immediate personal rights risk to residents in care.
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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: 10/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4