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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201167
Report Date: 04/19/2023
Date Signed: 04/19/2023 11:55:02 AM


Document Has Been Signed on 04/19/2023 11:55 AM - 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 VALLEYFACILITY NUMBER:
019201167
ADMINISTRATOR:ESPINOZA, MARISSA KFACILITY TYPE:
740
ADDRESS:7601 AMADOR VALLEY ROADTELEPHONE:
(360) 836-4604
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY:80CENSUS: 38DATE:
04/19/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Elisa Graber, Director of SalesTIME COMPLETED:
10:38 AM
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On 4/19/2023 at 9:20AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a health and safety check as a result of a priority 2 complaint. LPA met with Director of Sales, Elisa Graber. Executive Director (ED) Marissa Espinoza was not available at the time. LPA asked Elisa to called ED to informed her the reason for visit, also obtained verbal permission for Elisa to sign the report.

LPA toured facility including but not limited to the resident bedrooms, bathrooms, common area, kitchen, and outdoor area. Facility temperature was maintained at 73 degrees F. Hot water temperature was measured at 119 degrees F in a resident's bathroom sink. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Facility order food supplies twice a week. Refrigerator was 31 degrees F and freezer was -2 degrees F. Resident's medications were kept locked in the medication room. Smoke detectors are interconnected with sprinkler system. Carbon monoxide detector observe. First-aid kit was complete. Fire extinguisher was observed to be full. There are no accessible bodies of water observed.

No deficiencies are being cited on this date.

Exit interview conducted. A email of this report was provided
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2023
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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