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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201167
Report Date: 08/02/2024
Date Signed: 08/02/2024 12:21:25 PM


Document Has Been Signed on 08/02/2024 12:21 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:
11:00 AM
MET WITH:Marissa Espinoza, Executive DirectorTIME COMPLETED:
12:30 PM
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On 08/02/2024 at 11:00 AM Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 06/19/2024. LPA met with Executive Director, Marissa Espinoza and explained the purpose of the visit

LPA received a SOC 341 from Reporting Party (RP) indicating that there was a altercation between R1 and R2. Staff immediately intervened and separated both R1 and R2. No further issues with the residents.

LPA L. Alexander collected documents pertinent to the incident report.

No deficiencies issued during the visit.

Exit interview conducted and a copy of this report was 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
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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