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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201167
Report Date: 01/16/2024
Date Signed: 01/16/2024 06:30:58 PM


Document Has Been Signed on 01/16/2024 06:30 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 VALLEYFACILITY NUMBER:
019201167
ADMINISTRATOR:ESPINOZA, MARISSA KFACILITY TYPE:
740
ADDRESS:7601 AMADOR VALLEY ROADTELEPHONE:
(925) 361-0913
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY:80CENSUS: 54DATE:
01/16/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
05:10 PM
MET WITH:Brandie Barrios, Connections For Living Director TIME COMPLETED:
06:50 PM
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On 1/16/2023 at 4:30PM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a health and safety check as a result of a priority 1 complaint. LPA met with Connections For Living Director, Brandie Barrios. Executive Director (ED) Marissa Espinoza was not available at the time.

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. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. 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. Fire extinguisher was observed to be full. There are no accessible bodies of water observed.

At 1/16/24 at 5:15PM during the health and safety checked LPA did a random checked of hot water temperature in five resident room in memory care until. 5 residents’ temperature were measured above 121 degree F.

Type A deficiency is cited per Title 22 California Code of Regulations.

Exit interview was conducted with Brandie. A copy of this report and Appeal Rights were provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2024
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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Document Has Been Signed on 01/16/2024 06:30 PM - It Cannot Be Edited

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 VALLEY
FACILITY NUMBER: 019201167

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/17/2024
Section Cited
CCR
87303(e)(2)

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Maintenance and Operation. Hot water provided for the use of residents shall be maintained between 105 and 120 degrees F.
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Administrator shall ensure hot water temperature is kept within regulations. Administrator shall adjust hot water temperature to comply with regulation. Written certification required showing regulation has been read and hot water temp has been turned down. Proof of correction to be sent to CCLD by POC date.
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5 residents’ room temperature were measured above 121 degree.
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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 FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2