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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200665
Report Date: 02/25/2023
Date Signed: 02/25/2023 12:19:43 PM

Document Has Been Signed on 02/25/2023 12:19 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 HAVEN RESIDENTIAL CAREFACILITY NUMBER:
019200665
ADMINISTRATOR:GOLITZEN, MARIA GRACIAFACILITY TYPE:
735
ADDRESS:951 MALCOLM LANETELEPHONE:
(510) 274-5543
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 6CENSUS: 3DATE:
02/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Chioma Dimude/LicenseeTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced annual/infection control inspection. LPA met with staff, Rosemarie Wright, and informed the purpose of visit. LPA called Maria Golitzen; no answer. LPA called Chioma Dimude, licensee, who arrived after about 20 minutes.

Facility has an approved LIC808 Mitigation Plan. The LIC9282 Infection Control Plan has not been submitted.

LPA toured the facility inside out with Rosemarie Wright. LPA inspected the living room, dining area, kitchen, hallways, residents bedrooms, bathrooms, side and backyard. There's adequate food supplies of perishables good for 2 days and non-perishables good for 7 days. Central storage for medications and storage for cleaning supplies were observed locked.

LPA observed screening station near the front entrance with hand sanitizer, no touch temperature probe. Facility has Visitor's log. Temperature and symptom checks are done at the entrance. Facility keeps record of proof of vaccination of residents and staff. Supplies of PPEs checked. COVID-19 signages were observed inside the facility. Trash bins were observed with touch free lids.

Fire extinguisher checked, and observed fully charge with tag showed serviced December 12, 2022. Hot water temperature in the common bathroom was tested and measured at 106.5 degrees Fahrenheit.



......continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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 HAVEN RESIDENTIAL CARE
FACILITY NUMBER: 019200665
VISIT DATE: 02/25/2023
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LPA observed the following:
1. No Covid-19 signages on the front entrance door.
2. No "Wear Mask" posters in the common area and front door entrance.
3. Supplies of N95 respirators, disposable gown and surgical masks not sufficient for 30 days for 7 staff.

Licensee and/or administrator to submit the following by March 10, 2023:
1. LIC308 Designation of Facility Responsibility
2, LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Current N95 fit testing records/certificates for staff
5. Proof of Surety bond coverage
6. LIC9282 Infection Control Plan

No deficiency cited.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2023
LIC809 (FAS) - (06/04)
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