019201167-8-19-2025-15-AS-AGHO-DKPTCL-20250819143656

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019201167
Report Date: 08/19/2025
Date Signed: 08/19/2025 02:37:05 PM

Document Has Been Signed on 08/19/2025 02:37 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 VALLEY		FACILITY NUMBER:	019201167
ADMINISTRATOR/ DIRECTOR:	ESPINOZA, MARISSA K		FACILITY TYPE:	740
ADDRESS:	7601 AMADOR VALLEY BLVD		TELEPHONE:	(925) 361-0913
CITY:	DUBLIN	STATE: CA	ZIP CODE:	94568
CAPACITY: 80		CENSUS: 76	DATE:	08/19/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:15 AM
MET WITH:	Vercina Curley, Interim Executive Director		TIME VISIT/ INSPECTION COMPLETED:	03:50 PM

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On 8/19/2025 at 10:30am Licensing Program Analysts (LPAs) Ardalan Gharachorloo and Kelly Nguyen arrived unannounced to conduct a Required - 1 Year inspection at approximately, and met with Interim Executive Director, Vercina Curley and explained the purpose of the visit.

LPAs toured the facility with the Interim Executive Director and observed some COVID-19 precaution signs posted in common areas to promote hand washing and physical distancing. Infection Control Policies last updated on 12/4/2024.

This facility is licensed to serve up to 80 residents. There are 4 floors being used and the facility consists of living room/front area, activity rooms, gym, theater room, indoor outdoor dining and 80 private residence rooms. No accessible bodies of water or fire safety hazards observed. Fire Extinguisher were found to be charged and serviced 9/3/2025. Floors have stair evacuation chairs. The facility has hard wire Smoke alarms, fire sprinklers that are serviced yearly and Carbon monoxide detectors. Hot water measured at an average of 102.6 Degree Freiheit of sample residents’ apartments. Fire Drill last conducted on 7/18/25. Liability Insurance issue on 6/1/2025 to 6/1/2026 under Amador Valley I, LLC 7601 in addition to DBA Emerald Valley. Car registration issue from 9/30/24 to 9/30/2025.

LPAs reviewed 6 clients’ records and 10 staff records, and all were complete. A sample of 6 residents’ medications were reviewed.

Exit interview conducted with Interim Executive Director a copy of this report is provided

No deficiencies cited during this inspection

NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Ardalan Gharachorloo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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