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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
075600780
Report Date:
09/15/2022
Date Signed:
09/15/2022 02:04:30 PM
Document Has Been Signed on
09/15/2022 02:04 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 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:
6
DATE:
09/15/2022
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
11:00 AM
MET WITH:
Lailo Matias
TIME COMPLETED:
02:30 PM
NARRATIVE
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On 9/15/22 at 11:00 AM, Licensing Program Analyst (LPA) J. Sampair conducted an infection control annual inspection. Upon arrival, LPA explained the purpose of the visit to staff. Administrator Lailo Matias arrived shortly after LPA had toured the facility inside and outside.
Facility has an infection control plan in place that they are following. The designated infection control leader is the administrator. They have one central entry point that has been designated for universal entry screening with the station located near the front entrance with visitor's log, hand sanitizer, face masks, and no touch thermometer. Facility follows daily cleaning, sanitation of frequently touched common surfaces with disinfectants. COVID-19 signs were posted to promote hand washing, cough/sneeze etiquette and physical distancing.
The temperature inside of the facility was 72.7 and the hot water temperature was 117, which were in the safe temperature range. An administrator is on site at least the required 20 hour minimum each week to oversee business operations.
Facility cited for 2 Type A and 3 Type B deficiencies (refer to LIC 809-D).
Exit interview conducted, copy of Appeal Rights, and a copy of this report provided via email
SUPERVISOR'S NAME:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
James Sampair
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
09/15/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/15/2022
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
4
Document Has Been Signed on
09/15/2022 02:04 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 CARE HOME
FACILITY NUMBER:
075600780
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/15/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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
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4
Based on observation, the licensee did not comply with the section cited above in the garage where flammable items were stored inside of the hot water closet, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
09/16/2022
Plan of Correction
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3
4
Cleared during visit.
Type A
Section Cited
CCR
87555(b)(23)
General Food Service Requirements
(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in the refrigerator and freezer with loose fitting covers and no dating of when foods were opened, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
09/16/2022
Plan of Correction
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2
3
4
Licensee must securely cover and date all food in the refrigerators and the freezers in the facility.
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:
09/15/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/15/2022
LIC809
(FAS) - (06/04)
Page:
2
of
4
Document Has Been Signed on
09/15/2022 02:04 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 CARE HOME
FACILITY NUMBER:
075600780
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/15/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
Prior to construction or alterations, all facilities shall obtain a building permit.
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 in the garage, where they had built a wall to hold a room partition where staff were using it as a bedroom, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/22/2022
Plan of Correction
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2
3
4
Licensee must remove wall and partition and the staff members are not allowed to use the garage as a bedroom.
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above for the side gate that was built with beam across it that obstructs safe use, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/22/2022
Plan of Correction
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4
Gate at side of home must be rebuilt without an obstruction, allowing for safe entrance and exit.
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:
09/15/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/15/2022
LIC809
(FAS) - (06/04)
Page:
3
of
4
Document Has Been Signed on
09/15/2022 02:04 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 CARE HOME
FACILITY NUMBER:
075600780
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/15/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87203
87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above because the fire extinguisher had not been replaced or serviced within the past 12 months, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/22/2022
Plan of Correction
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2
3
4
Cleared during inspection with purchase of new fire extinguisher.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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:
09/15/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/15/2022
LIC809
(FAS) - (06/04)
Page:
4
of
4