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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200665
Report Date: 01/10/2025
Date Signed: 01/10/2025 01:01:09 PM

Document Has Been Signed on 01/10/2025 01:01 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:EMERALD HAVEN RESIDENTIAL CAREFACILITY NUMBER:
019200665
ADMINISTRATOR/
DIRECTOR:		GOLITZEN, MARIA GRACIAFACILITY TYPE:
735
ADDRESS:951 MALCOLM LANETELEPHONE:
(510) 274-5543
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 6CENSUS: 3DATE:
01/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Assistant Administrator Mankaa (Stephanie) CheTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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On 1/10/2024 at 8:00 AM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct an annual required inspection. The LPA informed Staff Members Cajetan (Chima) Emesim and Cyril Ezeh of the reason for visit. Assistant Administrator Mankaa (Stephanie) Che arrived at approximately 9:00 AM.

LPA inspected the facility inside and outside with the staff and assistant administrator. The inspection included the kitchen, dining area, living room, bedrooms, bathrooms, and yards. 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 12/6/2024. Fire extinguisher checked, observed to be fully charged with tag showing that it was last serviced 1/18/2024. Hot water temperature in the kitchen was measured at 116.4 degrees Fahrenheit.

LPA reviewed 3 resident and 5 staff records.


Continued on 809-C . . .
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: EMERALD HAVEN RESIDENTIAL CARE
FACILITY NUMBER: 019200665
VISIT DATE: 01/10/2025
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. . . Continued from LIC809

By 1/17/2025, Licensee shall send to LPA:
  • Proof of LIC308 Designation of Facility Responsibility showing 24/7/365 continuity
  • Proof of Posting: 2021 LIC610D Emergency Disaster Plan (9 pages)
  • Proof of Posting LIC999 Yard Sketch
  • Proof of Surety Bond coverage
  • Proof of Liability Insurance coverage

LPA observed the following:
  • At 10:35 AM: Expired First Aid for staff members S3, S4, and S5.

1 B-Type Citation issued.

Deficiencies and plan and proof of corrections were discussed with the assistant administrator. Deficiencies are cited from Title 22 California Code of Regulations and listed on 809-D. 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.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form, and copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/10/2025 01:01 PM - It Cannot Be Edited


Created By: James Sampair On 01/10/2025 at 12:35 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: 01/10/2025

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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Based on record review, the licensee did not comply with the section cited above in 3 of 5 staff member records had expired first aid/CPR, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/24/2025
Plan of Correction
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On or before due date, Licensee shall have staff members S3, S4, S5, and all other staff members with expired first aid/CPR register and complete the training, and submit copy of certificate to LPA Sampair.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2025


LIC809 (FAS) - (06/04)
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