015601128-5-21-2024-15-AS-GLUK-D5H3ZV-20240521184210

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601128
Report Date: 05/21/2024
Date Signed: 05/21/2024 06:42:28 PM

Document Has Been Signed on 05/21/2024 06:42 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	EMERALD HOME CARE		FACILITY NUMBER:	015601128
ADMINISTRATOR:	NICA, JOHN		FACILITY TYPE:	740
ADDRESS:	7314 EMERALD AVE.		TELEPHONE:	(925) 398-8807
CITY:	DUBLIN	STATE: CA	ZIP CODE:	94568
CAPACITY:	6	CENSUS: 1	DATE:	05/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Carmen Nica, Manager Merlene Sulph, Caregiver		TIME COMPLETED:	06:50 PM

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	On 5/21/2024 at 2:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with caregiver, Merlene Sulph and explained the purpose of the visit. Manager, Carmen Nica arrived an hour later, but was unable to stay until the end of inspection. The facility’s fire clearance was approved for 1 ambulatory and 5 non-ambulatory residents of which 2 residents maybe under hospice care. LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. Smoke and carbon monoxide combination detectors were observed. Fire extinguisher was observed to be full. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 111.6 degrees F in the hallway bathroom. LPA observed grab bars and non-skid mat in the bathrooms. There were adequate lights in each room. Resident rooms were observed to be cleaned and fully furnished. Last fire drill was conducted on 3/15/2024. LPA reviewed resident and 3 staff files starting at 2:50PM. LPA reviewed a sample of resident's medications during inspection. LPA interviewed resident and staff starting at around 5:15PM. At 2:20PM, LPA observed unlocked cleaning supplies in the staff room, unlocked knives in the kitchen, and unlocked gardening tools in the backyard. Staff locked up the cleaning supplies, knives, and gardening tools during inspection. At 2:30PM, LPA observed unlocked medications in the staff room, refrigerator, and kitchen drawer. Staff locked up the medications during inspection. (Continue on LIC809C...)

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: EMERALD HOME CARE	FACILITY NUMBER: 015601128
	VISIT DATE: 05/21/2024

NARRATIVE

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At 3:00PM, LPA observed R1 does not have a current medical assessment and appraisal needs & service plan on file.

At 5:30PM, LPA was informed that staff does not document resident's changes in condition. LPA did not observe facility notes or care notes for resident.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted with Merlene Sulph. A copy of this report and appeal rights was provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/21/2024 06:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: EMERALD HOME CARE	FACILITY NUMBER: 015601128
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having unlocked knives, gardening tools and cleaning supplies which poses an immediate health and safety risk to persons in care.
	POC Due Date: 05/22/2024
	Plan of Correction
1 2 3 4	Staff locked up the knives, gardening tools, and cleaning supplies during inspection. Deficiency cleared.

Type A

Section Cited

CCR

87465(h)(2)

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having unlocked medications which poses an immediate health and safety risk to persons in care.
	POC Due Date: 05/22/2024
	Plan of Correction
1 2 3 4	Staff locked up the medications during inspection. Deficiency cleared.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/21/2024 06:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: EMERALD HOME CARE	FACILITY NUMBER: 015601128
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87466

Observation of the Resident

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above by not documenting resident's changes in condition which poses a potential health and safety risk to persons in care.
	POC Due Date: 06/11/2024
	Plan of Correction
1 2 3 4	Facility has agreed to provide a written plan on how to address documenting resident's changes in condition and submit a copy to CCLD by POC date.

Type B

Section Cited

CCR

87705(c)(5)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not having current medical assessment and reappraisal for R1 which poses a potential health and safety risk to persons in care.
	POC Due Date: 06/11/2024
	Plan of Correction
1 2 3 4	Facility has agreed to obtain current medical assessment (LIC602) and current reappraisal (LIC625). Facility will submit copies to CCLD by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC809 (FAS) - (06/04)

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