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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700734
Report Date: 11/22/2021
Date Signed: 11/22/2021 10:13:53 AM

Document Has Been Signed on 11/22/2021 10:13 AM - 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:EMERALD HOMEFACILITY NUMBER:
342700734
ADMINISTRATOR:RAGCHAA, BAYARMAAFACILITY TYPE:
735
ADDRESS:9053 OLD CREEK DRIVETELEPHONE:
(279) 333-4419
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 4CENSUS: 0DATE:
11/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Bayarmaa RagchaaTIME COMPLETED:
10:20 AM
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On November 22, 2021 at 9:15am Licensing Program Analyst (LPA) Chris Hopkins arrived at Emerald Home for the purpose of conducting an unannounced required 1 year annual inspection. LPA met with Administrator, Bayarmaa Ragchaa and together conducted a tour of the home.

This facility has a census of 0. LPA and Administrator evaluated the physical plant to ensure the health and safety of the future residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility.

LPA observed sufficient seven-day non-perishable. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed where centrally stored medications will be kept, and there is a lock on the cabinet to secure from residents. The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point and has implemented screening and sign in procedures at the front door area. LPA observed the facility to have hand washing stations, COVID - 19 informational signage, and social distancing signs posted throughout the facility. The facility has a designated infection control lead individual. The facility is able to designate and dedicate a Covid-19 room/bathroom if needed.

LPA Requested the following documents for facility file:
  • LIC 308 Designation of Facility Responsibility
  • Current Administrator Certificate- Exp: 12/6/2022

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Christopher Hopkins-Clarke
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2021
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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