075600780-10-14-2021-15-AS-JSAR-C7SVF2-20211014162314

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075600780
Report Date: 10/14/2021
Date Signed: 10/14/2021 04:30:51 PM

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 CARE HOME		FACILITY NUMBER:	075600780
ADMINISTRATOR:	MATIAS, LAILO A.		FACILITY TYPE:	740
ADDRESS:	113 ROCK OAK COURT		TELEPHONE:	(925) 935-7899
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94598
CAPACITY:	6	CENSUS: 4	DATE:	10/14/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:08 AM
MET WITH:	Lailo Matias		TIME COMPLETED:	04:39 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	Licensing Program Analyst (LPA) James Sampair conducted an infection control annual inspection and explained the purpose of the visit with Administrator (ADM) Lailo Matias. LPA inspected the facility inside and outside. All of the staff and residents were fully vaccinated. LPA observed screening station located near the front entrance with a visitor's log, hand sanitizer, face masks, and a no-touch temperature probe. Routine symptom screening (+/-) temperature and symptom check is done at entry for all staff, residents, and visitors. LPA observed COVID-19 signs posted in common areas to promote hand washing and physical distancing. Facility documents daily temperatures for staff and residents. However, LPA observed that 0 of the 2 staff present upon entering facility wearing face masks. When ADM arrived, she was wearing a face mask. ADM is the designated Infection control leader. LPA discussed the mitigation plan with her, as well as their current COVID-19 infection control practices, and though ADM said that they had conducted staff training on infection prevention, symptoms, transmission, as well as the proper donning and doffing of PPE, they were not following a whole host of Infection Control practices, including: - Not following PIN 21-40-ASC with Visitor COVID-19 Vaccination verification from any of the visitors who entered the facility while LPA was present. - Only documenting temperature and not general well-being of residents. - No designated visitation area. - Did not have cough etiquette reminders posted. - Not aware of positive COVID-19 practices and procedures. - No procedures developed for accepting back residents following discharge from hospital. - FIT testing not completed nor scheduled. - Only had a PPE supply for less than one week. - Daily changes in resident health status not being recorded. -------Continued on 809-C-----------

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021

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 19

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 CARE HOME	FACILITY NUMBER: 075600780
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above due to blocking of an emergency exit by restricting access to unsafe outside ramp by locking of exit door, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/15/2021
	Plan of Correction
1 2 3 4	Door must be unblocked .

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above because the temperature of the water was 123 degrees Farenheit, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/15/2021
	Plan of Correction
1 2 3 4	Water temperature must be decreased to the safe range of 105 to 120 degrees Farenheit.

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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021

LIC809 (FAS) - (06/04)

Page: 2 of 19

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 CARE HOME	FACILITY NUMBER: 075600780
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87307(d)(4)

Personal Accommodations and Services

(4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above due to a ramp being damaged and therefore unusable for the emergency exit from the facility, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/15/2021
	Plan of Correction
1 2 3 4	Ramp repaired and proof of those repairs sent to LPA.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021

LIC809 (FAS) - (06/04)

Page: 3 of 19

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 CARE HOME	FACILITY NUMBER: 075600780
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(d)(2)

Personal Accommodations and Services

(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above because the gate on the edge of the deck leads to a damaged and unsafe ramp to the backyard, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/18/2021
	Plan of Correction
1 2 3 4	The ramp must be repaired.

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 4 of the past 5 quarters, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/18/2021
	Plan of Correction
1 2 3 4	The fire drill for this quarter must be conducted.

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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021

LIC809 (FAS) - (06/04)

Page: 4 of 19

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 CARE HOME	FACILITY NUMBER: 075600780
	VISIT DATE: 10/14/2021

NARRATIVE

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There were sufficient food and water supplies in the kitchen refrigerators/freezers. Emergency paper and PPE supplies were observed. Facility room temperature was maintained at a comfortable temperature.

A certified administrator is on site at all times to oversee proper business operation and compliance with COVID-19 infection control practices. Fire extinguishers were observed fully charged and last inspected in June 2021 and the Smoke and Carbon monoxide detectors were fully operational.

LPA observed three (3) Type A deficiencies and two (2) Type B deficiencies, the details of which are in the LIC809-D citations.

Exit interview was conducted and a copy of this report and copies of the Appeal Rights were provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021

LIC809 (FAS) - (06/04)

Page: 19 of 19