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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200392
Report Date: 12/29/2023
Date Signed: 12/29/2023 04:56:25 PM

Document Has Been Signed on 12/29/2023 04:56 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:EMA BOARD AND CAREHOMEFACILITY NUMBER:
079200392
ADMINISTRATOR:EDWIN LIWANAGFACILITY TYPE:
740
ADDRESS:1131 ALAMO WAYTELEPHONE:
(925) 458-7098
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 10CENSUS: 6DATE:
12/29/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:20 PM
MET WITH:Edwin Liwanag, AdministratorTIME COMPLETED:
05:05 PM
NARRATIVE
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On 12/29/2023 at 4:20pm, Licensing Program Analysts (LPAs) L. Hall and T. Syess-Gibson arrived to conduct an case management visit. LPAs met with Edwin Liwanag, Administrator and explained the reason for the visit.

While LPAs L. Hall were conducting a complaint investigation (15-AS-20231219162259) on 12/29/2023. During record review LPAs observed that S1 had not reported to CCLD that R2 had been hospitalized and admitted into hospice services.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of the appeal rights and this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2023
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 2
Document Has Been Signed on 12/29/2023 04:56 PM - It Cannot Be Edited


Created By: Laura Hall On 12/29/2023 at 04:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: EMA BOARD AND CAREHOME
FACILITY NUMBER: 079200392

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/08/2024
Section Cited

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: This requirement was not met as evidence by:
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Based on record review the Licensee did not comply with the section cited aboved in reporting an incident to CCLD which poses a potential health and safety risk to persons in care.
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Type B
01/08/2024
Section Cited

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87632 (d) If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver... (2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services... This requirement was not met as evidence by:
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Based on record review the Licensee did not comply with the section cited above in notifying CCLD by subimtting a hospice notification which poses a potential health and safety risk to persons in care.
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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
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 12/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2023


LIC809 (FAS) - (06/04)
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