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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201167
Report Date: 08/02/2024
Date Signed: 08/02/2024 12:18:27 PM


Document Has Been Signed on 08/02/2024 12:18 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
E BAY DELTA AC/SC, 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: 72DATE:
08/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Marissa Espinoza, Executive DirectorTIME COMPLETED:
11:00 AM
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 08/02/2024 at 10:15 AM Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 06/17/2024. LPA met with Executive Director, Marissa Espinoza and explained the purpose of the visit.

The Incident report stated that at approximately 9:20 PM, R1 was found outside the community lying face down in a bush. LPA interviewed S1 and S2 for further details. S1 stated that the Wander Guard alert went off and the alarm was heard. S1 stated that S3 went to R1's apartment to check if they were in their room and they observed that they were gone. S1 stated that S3 and S4 went outside looking and they observed R1 laying in a bush face down located in the front entrance of the facility. S1 stated that this occurred between 9-10 PM during shift change.

S1 stated that R1 had no injuries. S1 stated that the facility increased their safety checks for R1 throughout the night. S1 stated that there was a care conference with S1, S2 and R1's responsible party. S1 stated that they started "16 Checks" for R1. S1 stated that R1 moved to the memory care unit on 07/31/2024 which would provide oversight and simulation for R1.

LIC809-C Continued...
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2024
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 3


Document Has Been Signed on 08/02/2024 12:18 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: EMERALD VALLEY
FACILITY NUMBER: 019201167

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/09/2024
Section Cited
CCR
87468.2(a)(4)

1
2
3
4
5
6
7
To care, supervision, and ...meet their individual needs...by staff that are sufficient in numbers, qualifications, and competency...

This requirement was not met as evidence by:
1
2
3
4
5
6
7
By POC date, Licensee will submit to CCLD a detailed written plan on how they will address incidents of elopement and safety and also how they plan to mitigate this type of situation.
8
9
10
11
12
13
14
Based on interview, the licensee did not comply with the section cited above by not having the supervision which posed a potential health and safety risk to persons in care.
8
9
10
11
12
13
14
Type B
08/09/2024
Section Cited
CCR87211(a)(2)

1
2
3
4
5
6
7
(2) Occurrences...which threaten the welfare, safety or health of residents,...shall be reported within 24 hours...

This requirement was not met as evidence by:
1
2
3
4
5
6
7
By POC date, Licensee will submit to CCLD a detailed written plan on how they will address reporting incidents of elopement and safety including but not limited to all residents.
8
9
10
11
12
13
14
Based on interview and record review the licensee did not comply with the section cited above by not reporting to CCL within 24hrs which posed a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
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: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: EMERALD VALLEY
FACILITY NUMBER: 019201167
VISIT DATE: 08/02/2024
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
26
27
28
29
30
31
32
LIC809-C Continued...

LPA obtained a copy of R1's Physician's Report, Needs and Services Plan, Resident Assessment and Care Staff Schedule for 06/09/2024.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3