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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200665
Report Date: 01/11/2024
Date Signed: 01/11/2024 05:52:52 PM

Document Has Been Signed on 01/11/2024 05:52 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: 4DATE:
01/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Maria Gracia Golitzen/AdministratorTIME COMPLETED:
06:00 PM
NARRATIVE
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On this day, January 11, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Nenita Guzman and Rosemarie Wright, and informed the reason for visit. LPA called and spoke over the phone with Maria Gracia Golitzen, administrator. Administrator arrived after several minutes.

Administrator submitted the facility's Infection Control Plan which LPA received on April 3, 2023.

LPA started the inspection with Rosemarie Wright and continued with the administrator. LPA inspected the kitchen, dining area, living room, bedrooms, common and ensuite bathrooms, side yard and backyard. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications and storage for cleaning supplies were observed locked.

Facility has 2 in 1 smoke and carbon monoxide detectors that were tested, and observed functional. Facility conducts disaster and fire drills, and records showed last conducted December 15, 2023. Fire extinguisher checked, observed fully charge with tag showed serviced November 20, 2023. Hot water temperature in the common bathroom was tested and measured at 107.3 degrees Fahrenheit.

LPA reviewed 5 staff records, and interviewed 2 staff and 2 residents.



.....continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2024
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 HAVEN RESIDENTIAL CARE
FACILITY NUMBER: 019200665
VISIT DATE: 01/11/2024
NARRATIVE
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LPA received the following updated/current documents:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of Surety Bond coverage

LPA observed the following:
-at 2:35 pm, trash bin in the common bathroom without lid.
-at 2:40 pm, soiled carpet flooring in 2 of residents bedrooms.
-at 2:45 pm, broken patio chair and pieces of wood in the backyard.
-at 4:50 pm, staff (S4) First Aid certificate expired 1/02/24.

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12 month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with the administrator.

Due to time constraint, LPA will come back to continue inspection.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form, and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/11/2024 05:52 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 01/11/2024 at 05:15 PM
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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: EMERALD HAVEN RESIDENTIAL CARE
FACILITY NUMBER: 019200665

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section above for the following which pose potential safety and/or personal rights risks to persons in care: soiled carpet flooring in 2 of residents bedrooms; broken patio chair and pieces of wood in the backyard
POC Due Date: 01/25/2024
Plan of Correction
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Backyard was cleaned while LPA was still at the facility.
Adminiistrator to have the carpet flooring cleaned, and submit pictures by 1/25/24.
Type B
Section Cited
CCR
80088(f)(1)
Fixtures, Furniture, Equipment, and Supplies
(f) Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, or provide a breeding place or food source for insects or rodents. (1) All containers, including movable bins, used for storage of solid wastes shall have tight-fitting covers kept on the containers; shall be in good repair, shall be leakproof and rodent-proof.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above for trash bin in the bathroom without lid which poses a potential health risk to persons in care.
POC Due Date: 01/25/2024
Plan of Correction
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Corrected,
Administrator has the staff purchased trash bin with lid while LPA was at the facility.
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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 01/11/2024 05:52 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 01/11/2024 at 05:15 PM
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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: EMERALD HAVEN RESIDENTIAL CARE
FACILITY NUMBER: 019200665

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above for S4's expired First Aid certificate which poses a potential health, safety and/or personal rights risk to persons in care.
POC Due Date: 01/25/2024
Plan of Correction
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Administrator to have S4 register and complete the training, and submit copy of certificate by 1/25/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024


LIC809 (FAS) - (06/04)
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