<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200665
Report Date: 01/19/2024
Date Signed: 01/19/2024 04:48:07 PM

Document Has Been Signed on 01/19/2024 04:48 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:
01/19/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Maria Gracia Golitzen/AdministratorTIME COMPLETED:
04:45 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 this day, January 19, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the annual required inspection that was started on January 11, 2024. LPA was granted entry by staff, Rosemarie Wright, and informed the reason for visit. LPA also met with other staff, Nenita Guzman. Maria Gracia Golitzen, arrived after several minutes.

LPA reviewed 4 residents records and checked the P&I. Medications were inspected, compared with doctor's order of medications and LIC622 Centrally Stored Medication and Destruction Records.

No deficiency observed.

Exit interview conducted. Copy of this report provided to the administrator.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2024
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 1