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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601040
Report Date: 12/06/2021
Date Signed: 12/06/2021 02:06:21 PM

Document Has Been Signed on 12/06/2021 02:06 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:EMERALD GEM HOME CAREFACILITY NUMBER:
198601040
ADMINISTRATOR:SAMONTE, MICHELLE TORRESFACILITY TYPE:
735
ADDRESS:2420 LOGAN STTELEPHONE:
(909) 625-2757
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 6CENSUS: 6DATE:
12/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:S-1TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with S-1 and explained the purpose of today's visit.

This home consists of (3), (2) bathrooms, living room, kitchen, dinning area and attached garage. LPA toured grounds. All Clients residing at this facility receive case management services provided by San Gabriel Pomona Regional Center.

The following were observed/inspected: .
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility and throughout the facility.
  • Signs are posted to promote hand washing, cough/sneeze etiquette, and physical distancing were observed.
  • PPE supplies observed. Additional supplies are stored inside the garage.
  • Restrooms have hand soap, hand sanitizer and paper towels.
  • Additional toilet paper and napkins are stored inside the garage.
  • Additional hygiene supplies are are stored inside the garage.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed. Additional food supply is stored inside the garage.
  • Per S-1, all (6) clients are fully vaccinated. (5) out of (6) clients have the COVID-19 Booster.
  • Per S-1, all staff are fully vaccinated and have the COVID-19 Booster.
  • Medication reviewed for Client #1 through Client #6 (C-1 though C-6).
  • Staff responsible for direct care and supervision will wear masks.
  • Clients were be socially distanced according to local public health guidelines.

Exit interview conducted, a copy of this report and Appeal Rights were provided to S-2/Facility Administrator.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2021
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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