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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920258
Report Date: 10/03/2025
Date Signed: 10/03/2025 12:45:08 PM

Document Has Been Signed on 10/03/2025 12:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:EMERALD SENIOR CAREFACILITY NUMBER:
345920258
ADMINISTRATOR/
DIRECTOR:		TULENINOVA, NATALIAFACILITY TYPE:
740
ADDRESS:4824 ALEXON WAYTELEPHONE:
(916) 257-4525
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 4DATE:
10/03/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:17 AM
MET WITH:Natalia Tuleninova and Alek ProkhorovTIME VISIT/
INSPECTION COMPLETED:
12:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a complaint investigation when LPA observed the following deficiencies. LPA met with Administrator and explained the purpose of the visit.

When conducting interviews, LPA was informed that R1 has the tendency of eloping from the facility in multiple occasions since admission. LPA was informed law enforcement was contacted in multiple occasions due to the elopement. LPA further explained that incident reports are to be provided to Licensing within seven days of occurrence. Administrator further stated R1 was admitted to the hospital for evaluation, which Licensee then informed hospital that R1's level of care can no longer be managed at the facility and R1 will not return. LPA and Administrator discussed that residents are to be provided a reassessment and a 30 day eviction letter if wished to no longer retain.

When discussing about R2's level of care, LPA was informed that R2 was admitted to the facility with a stage 4 pressure wound, but R2 is no longer at the facility. LPA informed Administrator that facility is not allowed to retain or accept residents with prohibited health conditions without the approval from the Department.

As a result of today's visit, deficiencies observed. Please see LIC 809-D.

Exit interview and a copy of report and appeal rights provided.
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Cassie Yang
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 10/03/2025 12:45 PM - It Cannot Be Edited


Created By: Cassie Yang On 10/03/2025 at 11:42 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: EMERALD SENIOR CARE
FACILITY NUMBER: 345920258

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/04/2025
Section Cited
CCR
87616(a)

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87616 Exceptions for Health Conditions (a) As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition ... This requirement is not met as evidenced by:
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Licensee was provided CCR 87615 and CCR 87616 to review. Licensee is to submit a statement of understanding of the provided regulations to LPA Yang via email at cassie.yang@dss.ca.gov

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Based on file review and interview, Licensee did not comply as Licensee accepted R2 who has a prohibited health care condition without a exception granted which poses an immediate risk for residents in care.
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POC is due Saturday October 4, 2025. Failure to provide LPA the POC by due date may result to $100 civil penalty per day until POC received.
Type B
10/24/2025
Section Cited
CCR87224(a)(4)

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87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons... Thirty (30) days written notice to the resident is required... (4) If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted... This requirement is not met as evidenced by:
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Licensee was provided CCR 87224 to review. Licensee is to submit a statement of understanding of the provided regulation to LPA Yang via email at cassie.yang@dss.ca.gov
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Based on interview, Licensee did not comply as LPA was informed that Licensee informed hospital R1 cannot be discharged back to the facility due to R1's change of condition. 30 day eviction was not provided, which poses a potential risk for residents in care.
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POC is due Friday October 24, 2025. Failure to provide LPA the POC by due date may result to $100 civil penalty per day until POC received.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Cassie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/03/2025 12:45 PM - It Cannot Be Edited


Created By: Cassie Yang On 10/03/2025 at 11:59 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: EMERALD SENIOR CARE
FACILITY NUMBER: 345920258

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/24/2025
Section Cited
CCR
87211(a)(1)(D)

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including...
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence... (D) Any incident which threatens the welfare, safety or health of any resident... This requirement is not met as evidenced by:
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Licensee was provided CCR 87211 to review. Licensee is to submit a statement of understanding of the provided regulations to LPA Yang via email at cassie.yang@dss.ca.gov
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Based on interview, Licensee did not comply as LPA was informed there was two residents in care that had the tendency of eloping from the facility and R1 was admitted to the hospital for evaluation but an incident report was not submitted, which poses a potential risk for residents in care.
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POC is due Friday October 24, 2025. Failure to provide LPA the POC by due date may result to $100 civil penalty per day until POC received.

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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.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Cassie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2025


LIC809 (FAS) - (06/04)
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