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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201167
Report Date: 07/26/2024
Date Signed: 07/26/2024 02:07:37 PM


Document Has Been Signed on 07/26/2024 02:07 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 VALLEYFACILITY NUMBER:
019201167
ADMINISTRATOR:ESPINOZA, MARISSA KFACILITY TYPE:
740
ADDRESS:7601 AMADOR VALLEY ROADTELEPHONE:
(925) 361-0913
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY:80CENSUS: DATE:
07/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:17 AM
MET WITH:Marissa Espinoza, Executive DirectorTIME COMPLETED:
02:35 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 07/26/2024 at 11:27 AM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Marissa Espinoza and explained the purpose of the visit.

LPA toured the facility including but not limited to 4 residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 75 degrees F. The hot water temperature in a residents’ shared bathroom was measured at 115 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 09/10/2023. Emergency Disaster Plan was last posted on 02/16/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 06/13/2024.

LPA reviewed 6 residents records and 6 staff records, and all were complete. LPA also reviewed a sample of resident’s medications and medication logs.

The following documents were reviewed during the visit: LIC 500 Personnel Report, LIC 610E Emergency Disaster Plan, Liability Insurance and Current Administrator’s Certificate renewal documents.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Ardalan GharachorlooTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2024
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