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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601040
Report Date: 10/21/2022
Date Signed: 10/21/2022 12:40:40 PM

Document Has Been Signed on 10/21/2022 12:40 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
GREATER LA AC/SC, 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:
10/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Elizabeth Stacy/S-1TIME COMPLETED:
12:45 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 Elizabeth Stacy/S-1 and explained the purpose of today's visit.

This home consists of (3) bedrooms, (2) bathrooms, living room, kitchen, dinning area and attached garage. San Gabriel Pomona Regional Center provides case management to all the clients residing at this facility.

The following were observed/inspected: .
  • COVID-19 Infection Control Practices (including signs) were observed.
  • 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.
  • Incontinence supplies observed. Additional supplies are stored inside the garage.
  • Hygiene supplies (including feminine items) observed. Additional supplies are stored inside the garage.
  • Restrooms have hand soap, hand sanitizer and paper towels. Hand washings signs were also posted.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed.
  • Per S-1, all (6) clients are fully vaccinated and have both boosters.
  • Per S-1, all staff are fully vaccinated and have both boosters.
  • 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 Elizabeth Stacy/S-1
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2022
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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